LIBRARY0/ 


HOOKWORM  AND  MALARIA  RESEARCH  IN 
MALAYA,    JAVA,    AND    THE    FIJI    ISLANDS 


HOOKWORM  AND  MALARIA 
RESEARCH  IN  MALAYA,  JAVA, 
AND  THE  FIJI  ISLANDS 

REPORT  OF 

UNCINARIASIS  COMMISSION 

TO  THE   ORIENT 

1915-1917 


S.  T.  DARLING,  M.D. 
M.  A.  BARBER,  PH.D. 
H.  P.  HACKER,  M.D. 


PUBLICATION  NO.  9 


THE  (ROCKEFELLER  FOUNDATION 
INTERNATIONAL  HEALTH  BOARD 

NEW  YORK  CITY 
1920 


THE   RUMFORD   PRESS 
CONCORD,   NEW  HAMPSHIRE 


Libnury 


INTERNATIONAL  HEALTH  BOARD 

1  7  2- 

OFFICERS  AND  MEMBERS 

GEORGE  E.  VINCENT,  Chairman 

WICKLIFFE  ROSE,  General  Director 

HERMANN  M.  BIGGS 

WALLACE  BUTTRICK 

SIMON  FLEXNER 

FREDERICK  T.  GATES 

WILLIAM  C.  GORGAS  (Deceased) 

EDWIN  O.  JORDAN 

STARR  J.  MURPHY 

JOHN  D.  ROCKEFELLER,  JR. 

WILLIAM  T.  SEDGWICK 

VICTOR  C.  VAUGHAN 

WILLIAM  H.  WELCH 


EDWIN  R.  EMBREE,  Secretary 


ADMINISTRATIVE  STAFF 

WICKLIFFE  ROSE,  General  Director 
JOHN  A.  FERRELL,  M.D.,  Director  for  the  United  States 
VICTOR  G.  HEISER,  M.D.,  Director  for  the  East 
HECTOR   H.  HOWARD,  M.D.,  Director  for  the  West  Indies 
L.  W.  HACKETT,  M.D.,  Associate  Regional  Director  (for 

Brazil) 
ERNST  C.  MEYER,  PH.D.,  Director  of  Stwveys  and  Exhibits 


AUTHORS'  NOTE 

This  volume  represents  an  abridgment  of  the  detailed  report  sub- 
mitted by  the  undersigned  as  a  result  of  their  inquiries  into  the  extent 
and  importance  of  hookworm  disease  in  Malaya,  Java,  and  Fiji,  and 
the  comparative  significance  of  this  disease  and  malaria  as  disabling 
factors.  Mr.  Robert  Goldsmith  assisted  in  rewriting  and  condensing 
the  voluminous  data  which  comprised  our  original  manuscript  and 
arranged  them  in  their  present  convenient  form.  The  unabridged 
report  is  being  preserved  intact  in  the  library  of  the  Rockefeller 
Foundation,  where  persons  who  are  interested  may  consult  it. 

2.  Our  work  was  intended  to  make  no  effort  toward  the  control  of 
either  hookworm  disease  or  malaria.     Its  purpose  was  merely  in- 
vestigative.    The  authors  regret  that  in  many  cases  they  found  it 
impossible  to  secure  a  satisfactory  number  of  cases  for  their  experi- 
ments.    This   difficulty   applied   particularly   in   the   case   of   their 
studies   of   various   drugs   for   use   in   treating   hookworm   disease. 
Many  patients  absconded  during  the  rather  prolonged  periods  it  was 
necessary   to   keep   them   under  observation   and   treatment.     The 
reader  will  recognize  the  experiments  in  which  the  number  of  cases 
considered  was  perhaps  too  small  for  satisfactory  conclusions  to  be 
drawn  from  them,  and  will  understand  that  the  results  of  the  ex- 
periments are  to  be  taken  not  as  sufficient  in  themselves  to  establish 
facts,  but  as  subject  to  confirmation  by  more  extended  investigation. 
To  this  end  the  number  of  cases  considered  in  each  experiment  has 
been  clearly  indicated  in  each  of  our  various  tables  and  graphs. 

3.  It  should  be  understood,  further,  that  many  of  the  experiments, 
more   particularly  those   relating   to   the   treatment   of    hookworm 
disease,  were  carried  out  in  jails   and   hospitals.     It   may  be   that 
under  less  perfectly  controlled  conditions,  such  as  those  which  obtain 
in  the  field,  certain  differences  would  have  resulted  in  the  findings, 
which  in   turn   would   have   required  certain   modifications  in  our 
recommendations. 

4.  The  authors  desire  to  acknowledge  their  indebtedness  to  the 
medical  and  administrative  officers  of  the  countries  visited,  to  the 
planters,  and  to  the  other  officials  and  private  citizens  who  placed 
their  time  and  facilities  so  generously  and  unreservedly  at  the  dis- 
posal of  the  Commission.     Especial  thanks  are  due  Sir  Arthur  H. 
Young,  K.C.M.G.,  Governor  of  the  Straits  Settlements  and  High 
Commissioner  of  the  Federated  Malay  States;  Sir  Edward  L.  Brock- 
man,  K.C.M.G.,  Chief  Secretary  of  the  Federated  Malay  States;  Dr. 
Charles   Lane   Sansom,   C.M.G.,   Principal   Medical   Officer  of  the 
Federated  Malay  States;  Dr.  W.  Gilmore  Ellis,  P.C.M.O.,  Straits 
Settlements;  Dr.  W.  Th.  deVogel,  Hoofd  Inspecteur  Geneeskundigen 
Deinst  in  Nederlandsch  Indie;  and  Dr.  G.   W.  A.  Lynch,   P.M.O., 


X  AUTHORS     NOTE 

Fiji,  for  the  invaluable  opportunities  for  investigation  which  they 
accorded  the  Commission. 

5.  A  tabular  summary  of  the  findings  of  the  Commission  follows 
the  regular  text  matter  of  the  report.  This  summary  consists  of 
fifty-five  separate  tables,  pages  120  to  178.  The  more  important 
facts  presented  in  the  tables  have  been  arranged  in  graphic  form, 
and  the  graphs  have  been  placed  as  close  as  possible  to  the  text 
which  discusses  the  facts  they  exhibit.  There  is  a  separate  graph 
for  practically  every  table.  The  text  matter,  in  addition  to  being 
accompanied  by  the  graphs  which  relate  to  it,  contains  reference  to 
the  supporting  tables,  and  the  graphs  and  tables  in  their  turn  have 
been  given  proper  cross  references.  This  system  will  aid  the  reader 
to  locate  at  once  all  facts  bearing  on  any  particular  subject,  whether 
the  facts  be  in  graphic,  text,  or  tabular  form. 

S.  T.  DARLING 
M.  A.  BARBER 
H.  P.  HACKER 


CONTENTS 

CHAPTER  PAGE 

I     POPULATION  AND  LIVING  CONDITIONS 1 

II    ORIGIN  OF  THE  INVESTIGATION 12 

III  EXTENT  OF  THE  INVESTIGATION 16 

IV  METHODS  OF  EXAMINATION 22 

V    METHODS  OF  TREATMENT 32 

VI     FINDINGS  CONCERNING  HOOKWORM  INFECTION 47 

VII     FINDINGS  CONCERNING  MALARIA 65 

VIII     FINDINGS  CONCERNING  ANEMIA 83 

TABULAR  SUMMARY 118 


ILLUSTRATIONS 

PACE 

Map  of  Federated  Malay  States Facing  1 

Map  of  Java 6 

Men  and  women  as  beasts  of  burden 9 

The  hill  sawahs  of  Java 9 

One  of  the  canals  of  old  Batavia,  Java 10 

Food  being  sold  from  the  ground 10 

Laboratory  of  Uncinariasis  Commission  to  the  Orient,  Kuala  Lum- 
pur, Federated  Malay  States 13 

Interior  of  field  laboratory,  used  by  the  Commission  in  Java 13 

Scene  in  Batavia 14 

Group  of  night-soil  coolies  in  the  Federated  Malay  States 17 

Malay  boys'  school,  Kampong  Bharu,  Kuala  Lumpur 18 

Night-soil  disposal 23,  24 

Prisoners  in  Java  jail 29 

Dr.  Darling  making  the  hookworm  survey  in  Batavia  jail 29 

Squad  No.  3,  Java  jail 30 

Squad  No.  2,  Java  jail 30 

Hookworm  patient,  just  before  being  discharged  from  Kuala  Lum- 
pur hopsital 43 

Severe  case  of  hookworm  anemia  in  Chinese  youth 44,  45 

Group  of  former  residents  of  Federated  Malay  States  and  Straits 

Settlements  examined  at  St.  John's  quarantine  camp,  Singapore  .  .  46 

Two  cases  of  hookworm  anemia  in  Mid-Java 61 

Cases  of  hookworm  anemia  and  malarial  anemia  contrasted 62 

Estate  children 71 

Treatment  squad  in  Sawah  Besar,  Batavia 72 

People  of  Batavia  treated  at  Kampong  Kramat 75 

Two  cases  of  hookworm  infection  in  the  highly  malarious  kampong 

of  Jaagpad,  Java 75 

A  prolific  breeding  place  for  the  anophelines  which  spread  malaria  in 

Batavia 76 

Types  of  natives  in  treatment  squad  at  Tjimatjan,  Java 85 

A  vigorous  dessa  man  carrying  his  plow  on  his  shoulders  to  the  fields  85 
Seven  cases  of  hookworm  infection  with  anemia,  from  Karangsari  and 

Winosari 86 

Treatment  squad,  Jaagpad,  Batavia 86 

Group  of  children  living  on  an  unhealthful  rubber  estate  in  the 

Malay  States 97 

Tamil  children  on  an  estate  relatively  free  from  malaria 98 

Tamil  and  Chinese  with  severe  anemia  and  waxy  pallor 107 

Hospital  patient  just  before  discharge  and  after  hookworm  treat- 
ment   108 

Same  case  four  and  one-half  months  after  discharge  from  hospital . .  108 

xiii 


100 


105 


Fig  1. — Map  of  Federated  Malay  States 


CHAPTER   I 
POPULATION   AND  LIVING  CONDITIONS 

Before  the  work  of  the  Uncinariasis  Commission  to  the  Orient  is 
reviewed  in  detail,  the  chief  features  of  the  countries  visited  will 
be  briefly  discussed,  and  some  of  the  characteristics  of  their  people 
will  be  mentioned. 

I.     THE   FEDERATED  MALAY  STATES 

The  Malay  Peninsula  is  situated  in  the  most  southeasterly  portion 
of  Asia  and  extends  from  the  Isthmus  of  Kra  to  Cape  Romania,  a 
distance  of  750  miles  in  latitude  1.5°  to  6°  N.  Its  width  varies  from 
60  to  200  miles,  and  the  total  area  of  the  Peninsula  is  70,000  square 
miles.  The  area  of  the  Federated  Malay  States  alone  is  more  than 
25,000  square  miles. 

Topography  of  the  Country.  A  mountain  range  of  granite  and 
limestone  constitutes  the  backbone  of  the  Peninsula.  Certain  peaks 
in  this  range  reach 
a  height  of  8,000 
feet.  The  largest 
alluvial  tin  depos- 
its in  the  world 
are  situated  at 
the  foot  of  the 
western  slope  of 
these  mountains. 
Thecoastal  plains 
on  both  sides  of 
the  mountain 
range  extend 
from  five  to 
thirty  miles;  the 
eastern  plain, 
which  reaches  to 
the  China  Sea,  is 


Fig.  2. — Population  of  Federated  Malay  States. 
By  race.    Census  1911.     (Table  1) 


the  wider  of  the  two.     Many  mangrove  swamps  are  to  be  found  on 
the  western  coast,  which  terminates  at  the  Straits  of  Malacca. 

Climate  of  Malaya.  The  climate  of  Malaya  is  tropical  but  it  is 
less  oppressive  than  that  of  Panama,  for  example,  because  the 
porosity  of  the  soil  prevents  the  air  from  acquiring  the  highest  pos- 
sible degree  of  saturation.  Although  the  days  are  hot,  the  nights 
are  usually  cool.  There  are  no  prolonged  periods  of  drought  or  rain, 
but  there  are  between  150  and  200  rainy  days  each  year,  with  a  total 
annual  rainfall  ranging  from  75  to  150  inches. 

I 


INTERNATIONAL   HEALTH    BOARD 


Population  of  Malaya.  The  work  of  the  Commission  in  the 
Peninsula  was  confined  to  the  Federated  States  and  the  Straits 
Settlements.  The  population  of  these  states  in  1911,  according 
to  census  returns,  was  1,036,999.  (See  Tables  1  and  2,  pages  120  and 
121.)  Of  this  number  about  725,000  were  males  and  about  312,000 
females,  with  great  disparity  of  the  sexes  among  the  Chinese.  All 
native  adult  females  live  either  in  marriage  or  in  concubinage.  It 
is  an  interesting  fact  that  nearly  four-fifths  of  all  the  people  dwell 
in  rural  districts.  With  respect  to  religion,  when  the  last  census 
was  taken  it  was  found  that  of  the  total  population  there  were  about 

400,000  Mohammedans,  some 
136,000  Hindus,  approximately 
7,000  Sikhs,  and  about  23,000 
Christians.  Ancestral  worship 
was  practiced  by  nearly  all 
the  Chinese,  who  numbered 
more  than  350,000. 


300,000 


Character  of  the  Native 
Malay.  The  native  Malay  is, 
as  a  rule,  very  superstitious. 
He  believes,  for  instance,  that 
Hantu,  or  evil  spirits  who  live 
in  trees,  lurk  about  the  house 
at  night  and  exert  a  malignant 
influence  on  his  family,  his  ani- 
mals, his  crops,  and  himself.  It 
must  not,  however,  be  inferred 
from  this  that  all  Malays  are 
devoid  of  intelligence.  On  the 
contrary,  any  one  who  has  had 
experiencein  teaching  these  peo- 
Fig.  3. —  Population  increase  of  pie  is  enthusiastic  about  their 
Federated  Malay  States,  1901-1911.  mental  ability.  While  it  is  a 
By  race.  (Table  2)  common  opinion  that  all  Malays 

are  indifferent  and  indolent,  this 

is  not  the  case  except  in  the  Federated  States,  where  the  natives' 
wants  are  few  and  where  it  is  possible  for  them  to  supply  these 
wants  by  merely  a  modicum  of  labor.  In  Java,  where  the  popula- 
tion is  more  dense  and  where  there  is  consequently  a  real  struggle 
for  existence,  the  Malays  are  both  alert  and  industrious. 

It  is  therefore  proper  to  assume,  with  reference  to  permanent 
disease  control  measures,  that  both  men  and  women  would  not  be 
averse  to  receiving  instruction  in  hygiene.  But  it  is  not  highly 
probable  that  the  Malays  of  the  Federated  States  would  be  likely  to 
inaugurate,  or  even  to  co-operate  in  bringing  about,  sanitary  reforms 
which  require  concentrated  and  persistent  effort.  There  is  great 
lack  of  initiative.  It  may  be  that  intermarriage  and  concubinage 


POPULATION  AND   LIVING   CONDITIONS 


of  Malay  women  with  men  of  the  more  virile  races — particularly 
the  Chinese — will  in  the  course  of  time  have  the  effect  of  altering 
somewhat  the  present  listless  character  of  the  native. 

Character  of  the  Tamil  Coolie.  Most  of  the  Tamil  coolies  in 
the  Federated  States  come  from  the  Madras  Presidency  in  southern 
India,  and  are  in  the  main  ignorant,  superstitious,  and  servile. 
Probably  not  more  than  5  per  cent  of  them  are  able  to  write  their 
names.  While  it  is  true  that  Tamils  are  hard  workers,  it  is  also  true 
that  they  are  almost  entirely  lacking  in  ambition.  Docile,  unstable, 
and  apparently  quite  incapable  of  administering  their  own  affairs 
with  either  dispatch  or  intelligence,  they  constitute  the  white  man's 
burden.  But  for  the  best  interests  of  society  they  should  not  be 
permitted  to  exclude  themselves  from  the  civilizing  influence  of  edu- 
cation; in  their  case  there  is  marked  need  for  instruction  along  the 
lines  of  sanitation. 
Their  disinclina- 
tion, for  instance, 
to  use  the  latrines 
provided  by  the 
Government  or 
by  the  estates  on 
which  they  are  em- 
ployed, is  a  direct 
menace  to  the 
communityand,  it 
is  not  too  much  to 
say,  an  indirect 
menace  to  the 
world.  There  is 

no  doubt  that  the        Fig<  4-_Density  of  population,  Federated  Malay 
natives  carry  with    gtat       COmpared  with  other  countries.     (Table  3) 
them   large  num- 
bers of  hookworms,  and,  as  a  result  of  insanitary  habits,  dispense 
them  throughout  the  communities  in  which  they  settle. 

Character  of  the  Chinese  Coolie.  The  residence  of  the 
Chinese  coolies  in  the  Federated  Malay  States  is  usually  transitory. 
A  few  may  plan  to  remain  permanently,  but  for  the  most  part  it  is 
the  intention  of  these  migratory  people  to  work  and  save  for  a  com- 
paratively brief  period,  and  then  return  to  China. 

The  materia  medica  of  the  coolie  is  medieval.  Even  hospital 
attendants  have  been  known  to  eat  dog,  really  believing  it  to  be  an 
efficacious  remedy  for  certain  prevalent  diseases.  Such  ignorance, 
however,  must  not  be  taken  to  mean  that  the  coolies  are  altogether 
indifferent  to  the  importance  of  education.  The  fact  is  that  they 
are  not  averse  to  general  instruction  with  respect  to  both  personal 
hygiene  and  sanitary  reform.  But  probably  because  of  their  extraor- 
dinary racial  obstinacy  it  is  extremely  difficult  to  convince  the  coolies, 
2 


INTERNATIONAL   HEALTH    BOARD 


by  argument,  of  the  urgent  need  of  actually  doing  their   part  in 
effecting  such  reform. 

The  principal  diet  of  these  people  is  boiled  rice  with  some  pork, 
fowl,  or  fish,  and  a  number  of  vegetable  and  "paste"  dishes  highly 
seasoned  with  chilies.  All  except  Straits-born  Chinese  use  chop- 
sticks. The  Chinese  eat  more  generously  than  the  Tamils. 

Chinese  coolies  bear  the  brunt  of  the  hard  work  that  is  done  in 
Malaya.  In  round  numbers,  approximately  150,000  are  engaged  in 
mining,  65,000  in  agricultural  pursuits,  10,000  as  woodcutters,  and 
7,000  as  rickshaw  pullers.  Chinese  on  rubber  estates  receive  higher 

wages  than  Tamils.     One  reason 

is  that  they  are  more  efficient 
workers;  another  is  that  they 
suffer  less  from  malaria  infec- 
tion, and  for  that  reason  are  less 
expensive  to  keep  in  good  physi- 
cal condition.  Tamils  receive 
from  30  to  40  cents  a  day,  in 
Straits  currency.  (One  dollar 
in  Straits  currency  equals  about 
55centsinUnitedStates  money.) 
Chinese  tappers,  however,  are 
frequently  paid  as  much  as  50 
cents  a  day.  Between  wages 
and  hemoglobin  content  there 
is  a  marked  parallel  which  is 
more  than  a  mere  coincidence. 
In  other  words,  the  better 
physical  stamina  of  the  Chi- 
nese, as  contrasted  with  the 
Tamil,  means  higher  wages  for 
Fig.  5. — Population  of  Federated  the  former. 
Malay  States  living  on  estates. 
race.  (Table  4) 


1,000 
900 
800 
700 
600 
500 


100 


300 
200 


100 


" 


tm    up 

m    nm~nm 


m 


ALL  RACES 


INDIANS 


CHINESE 


MALAYS 


I  TOTAL  POPULATION 


I  ESTATE  POPULATION 


By 


Education  in  Malaya.     In 

1912  there  were  373  vernacular 
schools  in  Malaya — one  in  almost  every  village.  All  of  these  schools 
were  either  under  direct  government  control  or  aided  by  government 
grants.  There  were,  in  addition,  a  few  Tamil  and  a  few  Chinese 
schools  situated  where  the  Tamil  and  Chinese  populations,  respec- 
tively, were  particularly  numerous. 

Principal  Industries  of  Malaya.  The  principal  industries  of 
Malaya  are  mining  and  agriculture.  In  1912  a  little  over  280,000 
acres  were  leased  for  mining  purposes;  more  than  26,000  acres  were 
actually  occupied;  the  value  of  the  products  amounted  to  more  than 
384,000,000;  and  over  160,000  persons  were  engaged  in  one  or 
another  mining  industry,  tin  ore  being  the  chief  mining  product. 
Many  alluvial  fields  are  both  owned  and  worked  by  Chinese.  For 


POPULATION   AND   LIVING   CONDITIONS 


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500.000 
450.000 
400.000 
350.000 
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250.000 
200.000 
150.000 
100.000 
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AGRICULTURE 

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PERSONAL 
SERVICE 

GOVERNMENT 
SERVICE 

COMMERCIAL 
TRANSPORTATION 

MISCELLANEOUS 

rr?vl  MALE              ••FEMALE 

a  considerable  period  coffee  was 
the  principal  product  raised  on 
the  estates,  or  plantations,  but 
in  recent  years  planters  have 
been  growing  rubber  in  prefer- 
ence, because  it  is  so  much  more 
profitable.  Cocoanuts  and  rice 
are  also  grown;  in  the  year  1912 
over  150,000  acres  were  devoted 
to  the  former.  (SeeTables  4  and 
5,  pages  123  and  124.) 

Government  of  Malaya. 
Inasmuch  as  it  is  a  fixed  policy 
of  the  Rockefeller  Foundation 
International  Health  Board  al- 
ways to  work  in  the  closest 
possible  co-operation  with  the 
Government  in  the  countries 
where  it  is  laboring,  a  few  words 
will  be  said  about  the  history 
and  the  government  of  Malaya. 

Since  the  conclusion  of  the 
Panghor  Treaty  in  1874,  the 
Federated  Malay  States— Perak, 
Selangor,  Negri  Sembilan,  and 
Pahang — have  really  been  under  British  protection,  although  federa- 
tion was  not  actually  brought  about  until  1895 — twenty  years  after 
the  treaty  had  been  concluded.  The  non-federated  states  and  Johore, 
although  nominally  independent,  are  also  within  the  British  sphere 
of  influence. 

Thanks  to  the  British  occupation,  the  territory  has  been  opened 
to  agriculture,  and  good  transportation  facilities  have  been  provided. 
The  tin-mining  industry  has  been  so  thoroughly  developed,  and  has 
proved  so  successful,  that  it  has  yielded  an  annual  revenue  large 
enough  to  provide  for  many  public  works. 

Public  Health  Work  in  Malaya.  Among  the  more  impor- 
tant activities  of  any  country  are  those  that  pertain  to  the  health 
of  the  people.  Public  health  work  in  the  Federated  States  is  fairly 
well  established.  There  are  a  Principal  Medical  Officer  at  Kuala 
Lumpur,  a  Senior  Health  Officer  in  each  of  the  four  states,  and  a 
District  Health  Officer  in  each  of  the  several  districts  within  each 
state.  In  addition,  there  are  a  director  for  the  Institute  of  Medical 
Research,  a  pathologist,  a  bacteriologist,  a  chemist,  and  two  health 
officers  in  each  state.  The  health  work  is  so  organized  that  general 
and  district  hospitals  serve  as  centers.  Fourteen  of  these  are  pro- 
vided and  maintained  by  the  British  Government,  and  fifty-two 
by  tiie  Government  of  the  Federated  Malay  States.  There  is  also  a 


Fig.  6. — Population  of  Federated 
Malay  States  engaged  in  principal 
occupations.  Male  and  female. 
(Table  5) 


POPULATION   AND  LIVING   CONDITIONS  / 

Malaria  Board  and  a  Nursing  Association.  As  for  sanitary  con- 
ditions, the  water  supply  is  good  and  the  coolies  on  the  estates  are 
provided  with  proper  conveniences. 


II.     THE   ISLAND   OF  JAVA 


gao 


50 


30 


The  Territory  and  the  People.  In  order  that  the  findings  of 
the  Commission  might  be  made  more  generally  applicable  through- 
out the  Orient,  the  scope  of  the  investigation  was  extended  to  include 
the  islands  of  Java  and  Sumatra.  In  the  urban  communities  of  Java 
the  native  people  live  in  kam- 
pongs,  or  collections  of  houses 
with  fenced-in  gardens  shaded 
by  cocoanut,  sugar-palm,  and 
fruit  trees,  and  often  inclosed  by 
those  city  streets  occupied  by  the 
shops,  offices,  or  residences  of 
Europeans.  In  the  rural  com- 
munities the  people  live  in  des- 
sas,  or  native  villages  which 
accommodate  from  300  to  3,000 
persons.  These  dessas  are  sur- 
rounded by  rice  sawahs  and 
cane  fields. 

The  unhygienic  habits  of  the 
people,  and  the  lack  of  sanitary 
conveniences,  in  both  urban  and 
rural  communities,  are  such  as 
to  be  a  constant  menace  to 
public  health.  A  large  propor- 
tion of  the  men,  women,  and 
children  make  a  practice  of  def-  F'g-  8— Relation  between  length 
ecating  in  the  drains,  ditches,  °.f  tl™f*Pent,  in  infected  sawahs,  or 
and  canals,  near  public  market  "cefieMs,  and  number  of  hookworms 

harbored.     By  sex    and  age  groups, 
places,   beside    railroads,    along    jaya 

country    lanes,     and    in    rivers 

and  irrigation  channels.     Not  infrequently  they  bathe  their  bodies 

and  wash  their  rice  in  the  same  streams. 


II 
I 


GIRLS 


WOMEN 


BOYS 


MEN 


III.     THE   FIJI   ARCHIPELAGO 


General.  For  the  purpose  of  checking  up  the  findings  of  the 
Commission  in  the  Federated  Malay  States,  in  Java,  and  in  Sumatra, 
two  members  of  the  Commission  spent  three  months  in  the  Fiji 
Islands  and  there  conducted  extensive  inquiries. 


INTERNATIONAL   HEALTH    BOARD 

The  low  spleen  rate  of  Tamils  entering  the  Malay  States  at  Port 
Swettenham  from  South  India  led  to  the  belief  that  it  would  be 
possible  to  find  in  some  parts  of  the  tropics  districts  free  from  malaria, 
for  although  hookworm  disease  is  practically  universal  in  the  tropics, 
malaria  is  not  co-extensive  with  it.  Indeed,  it  is  known  that  Bar- 
bados and  many  of  the  islands  of  the  Pacific — including  the  islands 
of  the  Fiji  Archipelago — are  entirely  free  from  malaria.  The  fact 
that  the  studies  of  the  Commission  in  the  Federated  Malay  States 
had  been  very  largely  concerned  with  the  effect  of  malaria  and 
hookworm  infection  upon  Indians,  taken  in  connection  with  the 
fact  that  there  were  in  the  Fiji  Islands  a  large  number  of  free  and 
indentured  Indians  who  had  lived  there  for  from  six  months  to 
thirty  years,  convinced  the  Commission  that  Fiji  would  serve 
admirably  for  purposes  of  control  experiments.  The  island  of  Viti 
Levu,  the  largest  island  in  the  group,  was  selected  as  the  field  for 
intensive  study. 

Climate  of  Fiji.  The  climate  of  Fiji  is  tropical  but  very 
healthful,  for,  although  the  heat  of  the  sun  is  intense,  it  is  tempered 
during  the  day  by  cool  breezes  from  the  south  and  east.  At  night 
it  is  frequently  necessary  to  use  a  blanket.  The  heat  is  never  so 
enervating  there  as  in  either  Malaya  or  Java.  Natives,  both  men  and 
women,  are  of  large  stature  and  of  great  physical  endurance.  Their 
vigorous  condition  is  certainly  due,  at  least  in  part,  to  freedom  from 
malaria.  Moreover,  the  Indians  of  Fiji  also  seemed  to  be  in  better 
physical  condition  than  those  examined  in  Malaya.  The  Commis- 
sion did  not  find  it  possible  to  determine  scientifically  whether  this 
was  properly  attributable  to  the  more  bracing  climate  of  Fiji,  or  to 
the  fact  of  their  North  Indian  origin. 

Character  of  the  Native  Fijian.  The  native  Fijian  is  not 
disposed  to  engage  in  sustained,  monotonous  labor,  except  to  attend 
to  the  cultivation  of  his  own  taro  beds  in  the  village.  This  indisposi- 
tion may  be  due  to  either  custom  or  temperament,  or  it  may  be  due 
to  the  fact  that  he  is  a  land-owner  and  does  not  feel  the  necessity  of 
exerting  himself  continually.  However,  he  is  always  able  and 
willing  to  do  work  that  requires  the  exercise  of  great  strength  spas- 
modically, as  in  the  case  of  the  boatman,  the  drayman,  or  the 
housebuilder. 

Indian  Coolies  in  the  Fiji  Islands.  The  Indians  in  Fiji 
come  from  Calcutta  and  from  the  Madras  Presidency.  Their  term 
of  agreement  is  five  years,  and  their  wages  are  fixed  by  the  Indian 
Government.  During  the  period  of  their  indenture  they  receive 
free  medical  attention  in  the  plantation  hospitals,  which  are  in  charge 
of  European  physicians.  The  value  of  this  attention  becomes  evi- 
dent from  a  comparison  of  their  condition  with  that  of  free  or  unin- 
dentured  coolies,  who  have  no  such  privilege  of  free  medical  treat- 
ment. The  Government  requires  good  latrine  accommodations, 
and  careful  inspections  are  made  by  medical  authorities  to  see  that 


Fig.  9. — In    the    great    struggle    for    subsistence   in   the 

beautiful  island  of  Java,  men  and  women  become  beasts 

of  burden  but  are  not  brutalized  in  the  process 


Fig.  10. — The   hill  sawahs  of  Java.     Rice  and   potatoes 
are  cultivated  here.     Hookworm  infection  was  light 


Fig.  11. — One  of  the  canals  of  old  Batavia,  Java.     Here 
the    people    bathe,    urinate,    defecate,    and    wash    their 
clothing  and  rice.     Hookworm  incidence,  95.2%;   average 
number  of  worms,  49 


Fig.  12. — Food  being  sold  from  the  ground, 
of  spreading  worm  infection 


One  means 


POPULATION   AND   LIVING   CONDITIONS  II 

sanitary  regulations  are  complied  with.  Although  at  the  expiration 
of  their  term  of  indenture,  these  Indians  may  re-engage  for  an  extended 
period,  they  seem  to  prefer  to  acquire  small  holdings  of  from  eight 
to  ten  acres  and  to  settle  on  the  land  as  farmers;  or  else  they  choose 
to  go  into  business  in  a  small  way,  as  shopkeepers.  Very  few  ever 
returrfto  India,  although  continuous  residence  in  Fiji  for  a  period  of 
ten  years  entitles  them  to  free  return  transportation.  The  reason 
for  their  preference  is  evidently  that  in  Fiji  they  enjoy  greater 
prosperity  than  they  do  in  their  native  country. 

This  review  of  the  lands  visited  and  of  the  people  studied  is  of 
course  not  exhaustive.  It  merely  represents  an  attempt  to  provide 
a  general  background  for  the  more  detailed  description  of  the  Com- 
mission's labors  which  is  to  be  given  in  ensuing  chapters. 


CHAPTER   II 
ORIGIN   OF  THE   INVESTIGATION 

Preliminary  Inspection.  Early  in  1914  the  General  Director  of 
the  Rockefeller  Foundation  International  Health  Board  made  a  tour 
through  the  Orient.  His  object  was  to  observe  conditions  and  gather 
data  regarding  the  customs  and  habits  of  the  people  and  the  relation 
of  these  customs  and  habits  to  their  general  health  and  working 
efficiency.  The  itinerary  included  Egypt,  Ceylon,  the  Philippine 
Islands,  and  the  Federated  Malay  States.  Opportunities  were 
afforded  in  Malaya  to  study  conditions  from  Penang  to  Singapore, 
and  data  especially  prepared  in  advance  were  made  available  for  in- 
spection. A  number  of  rubber  and  cocoanut  estates  were  visited, 
and  some  2,000  coolies  were  clinically  examined.  There  were  indi- 
cations on  every  hand  of  the  universal  prevalence  of  hookworm 
disease,  as  well  as  of  malaria. 

Need  for  the  Investigation.  Considerable  uncertainty  was 
found  to  exist  among  the  planters  and  physicians  interviewed,  in 
regard  to  the  seriousness  of  hookworm  disease  as  a  menace  to  health 
and  as  a  detriment  to  efficiency.  While  the  limited  amount  of  reli- 
able data  available  pointed  to  malaria  as  the  principal  disabling  dis- 
ease on  the  estates,  there  was  also  much  convincing  evidence  that  on 
a  number  of  these  plantations  hookworm  infection  increases  and 
severe  anemia  results. 

The  anemia  which  results  from  malaria  cannot  be  distinguished 
from  the  anemia  which  is  due  to  hookworm  disease.  The  two  dis- 
eases are  in  fact  so  complicated  that  the  value  of  unverified  conclu- 
sions is  rendered  extremely  dubious.  In  view  of  this  large  element  of 
doubt,  it  was  felt  that  in  advance  of  any  recommendation  of  expendi- 
tures for  the  relief  and  control  of  hookworm  disease,  there  was  real 
need  for  a  scientific  investigation  by  an  independent  commission, 
fully  supplied  with  the  necessary  funds  and  equipment. 

Medical  men  were  in  agreement  as  to  both  the  possibility  of  de- 
termining the  relative  importance  of  hookworm  infection  as  a  dis- 
ease-producing entity,  and  the  desirability  of  settling  this  question 
before  any  considerable  amount  of  work  for  immediate  relief  and 
ultimate  control  should  be  undertaken. 

Appointment  of  Uncinariasis  Commission.  The  local  repre- 
sentatives of  the  British  Government  were  approached  with  reference 
to  their  attitude  concerning  the  appointment  of  a  commission  of 
inquiry.  It  developed  that  the  Government  was  not  only  friendly, 
but  cordially  sympathetic.  As  a  result,  it  was  agreed  in  conference 
at  Government  House,  Singapore,  that  the  first  effort  should  be 
directed  toward  ascertaining  the  facts.  The  appointment  of  a  com- 


Fig.   13. — Laboratory  of  Uncinariasis  Commission  to  the 
Orient,  located  at  Kuala  Lumpur,  Federated  Malay  States 


Fig.  14. — Interior  of  field  laboratory,  used  by  the  Commis- 
sion in  Java.  The  laboratory  was  placed  beside  a  great 
cement  open  drain  on  one  of  the  streets  of  the  kampong. 
Huge  floating  fecal  masses,  so  characteristic  of  rice-eaters, 
came  floating  down  the  drain.  Cholera  is  usually  present 
in  this  kampong 


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ORIGIN   OF   THE   INVESTIGATION  15 

petent  commission  of  scientific  investigators  was  authorized  by  the 
Board,  and  Dr.  Samuel  T.  Darling,  Dr.  Marshall  A.  Barber,  and  Dr. 
H.  P.  Hacker  were  selected.  Dr.  Darling  was  made  Chairman  of  the 
Commission  and  instructed  to  conduct  studies  in  such  places  and  in 
such  manner  as  might  be  deemed  expedient.  Authorization  was 
also  given  to  employ  the  necessary  clerks  and  technical  assistants. 
Task  of  the  Commission.  A  memorandum  of  instructions  was 
prepared  for  the  guidance  of  the  Commission  in  the  conduct  of  its 
investigations.  As  defined  in  this  memorandum,  the  purpose  and 
object  of  the  Commission  was  "to  determine  to  what  degree  Uncinaria 
infection  is  a  menace  to  the  health  and  working  efficiency  of  the 
people  in  the  country  under  consideration."  The  intimate  relation 
found  to  exist  between  malaria  and  hookworm  disease  as  disabling 
factors  made  it  necessary  for  the  Commission  to  devote  almost  as 
much  time  and  study  to  malaria  as  to  hookworm  disease,  in  order  to 
determine  the  relative  importance  of  the  two  infections  as  causes  of 
anemia.  The  Commission  came  to  be  known  as  the  Uncinariasis 
Commission  to  the  Orient. 


CHAPTER   III 
EXTENT  OF  THE   INVESTIGATION 

The  Commission  assembled  at  Kuala  Lumpur  on  June  2,  1915,  and 
there,  in  the  District  Hospital,  established  permanent  headquarters. 
There  were  465  beds  in  this  hospital;  the  daily  number  of  sick  aver- 
aged 334;  the  total  admissions  for  the  year  1915  amounted  to  4,868. 
Most  of  the  patients  were  suffering  from  dysentery,  malaria,  beriberi, 
ancylostomiasis,  or  tuberculosis.  From  these  facts  it  will  be  evident 
that  the  Commission  found  plentiful  material  available  for  study. 
Much  valuable  and  necessary  work  was  done  in  the  laboratory  here, 
by  way  of  training  assistants  and  developing  technical  skill.  They 
were  given  opportunity  to  study  cases  of  anemia  and  to  learn  methods 
of  treatment. 

For  a  month  after  arriving  at  Kuala  Lumpur,  the  members  of  the 
Commission  made  a  tour  of  the  vicinity  in  order  to  familiarize  them- 
selves with  the  new  situation.  It  became  evident  at  once  that  there 
was  much  malaria,  everywhere  and  among  all  classes,  and  moreover 
that  this  disease  was  responsible  for  an  enormous  amount  of  acute 
and  chronic  disability.  Malaria  surveys  were  made  in  a  number  of 
neighboring  localities,  in  the  course  of  which  anophelines  were  dis- 
sected to  determine  the  presence  of  malaria  plasmodia,  and  the  spleen 
and  parasite  rates  of  patients  were  taken  and  recorded. 

Plan  of  Action.  The  Commission  pursued  the  following  plan  in 
conducting  its  inquiry: 

(1)  It  studied  by  clinical  and  laboratory  methods  the  cause  of 
anemia  among  the  patients  who  were  admitted  to  a  large  general 
hospital. 

(2)  It  examined  at  the  detention  camps  at  Port  Swettenham  and 
Singapore  a  large  number  of  Tamil  and  Chinese  immigrant  coolies 
from  southern  India  and  southern  China.     At  Port  Swettenham  2,261 
Tamil  coolies  were  examined  and  at  Singapore  700  Chinese  coolies. 

(3)  It  treated  with  chenopodium,  or  some  other  vermicide,  a  con- 
siderable proportion  of  those  who  on  examination  showed  evidence 
of  hookworm  infection.     Of  the   2,261   Tamils   examined   at   Port 
Swettenham,  35  were  treated  individually,  and  391  in  groups  of  40. 
Of  the  391  treated  in  groups,  308  received  two  treatments  of  cheno- 
podium, and  83  two  treatments  of  thymol. 

(4)  It  made  every  effort  to  trace  the  treated  cases  to  the  several 
estates  and  mines  where  they  worked.     This  was  for  the  purpose  of 
re-examining  them  in  order  to  determine  the  effect  of  residence  in 
the  Federated  Malay  States  (and  consequent  exposure  to  hookworm 
infection  and  malaria)  on  their  general  health  and  working  efficiency; 
and  at  the  same  time  to  estimate  the  relative  effect  of  the  two  dis- 
eases in  causing  anemia,  and  to  determine  the  value  of  treatment. 

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EXTENT   OF   THE   INVESTIGATION  19 

Work  at  Port  Swettenham.  All  incoming  Tamil  coolies  were 
detained  at  the  quarantine  camp  at  Port  Swettenham  for  a  period  of 
one  week.  Nearly  all  of  the  Tamils  examined  (for  plasmodia  in  the 
blood,  and  for  ova  in  the  stools)  were  found  to  be  in  a  fair  condition 
of  health,  and  remarkably  free  from  ulcers  and  other  skin  diseases. 
Arrangements  at  the  camp  were  very  convenient  for  the  investiga- 
tions undertaken.  Twelve  inclosures  were  arranged  in  a  circle 
around  a  central  administrative  building,  and  were  so  constructed  as 
to  be  quite  independent  of  one  another.  Each  had  its  own  water 
supply  and  its  own  water-flushed  latrines,  with  proper  drainage 
system.  A  common  kitchen  was  situated  in  the  central  open  space. 
Thanks  to  the  generous  co-operation  of  the  authorities,  one  of  the 
buildings  was  temporarily  converted  into  a  laboratory  with  adequate 
facilities;  also  an  excellent  ward  in  the  camp  hospital  was  made  avail- 
able for  the  use  of  the  Commission. 

As  an  aid  to  future  identification,  a  history  of  each  coolie  was  taken. 
A  record  was  kept  of  his  father's  name,  his  own  name,  his  age,  his 
caste,  his  personal  characteristics,  and  the  village  of  his  origin.  A 
spot  map  was  made  not  only  showing  this  place  of  origin,  but  also 
giving  the  following  data:  anemic  cases;  whether  or  not  the  coolie 
was  found  negative  to  hookworm  infection  after  three  examinations; 
enlarged  spleens;  and  enlarged  spleens  in  relation  to  anemia.  The 
name  or  number  of  the  estate  to  which  each  coolie  was  going  was 
placed  on  a  disc  provided  by  the  immigration  authorities.  If  at  any 
time  previously  the  coolie  had  ever  left  India  for  any  other  country, 
he  was  rejected  for  the  purposes  of  this  investigation.  The  cases 
chosen  for  treatment  were  all  scheduled  to  go  to  estates  that  had 
selected  twenty  or  more,  a  number  sufficiently  large  to  justify  the 
Commission  in  paying  a  visit  to  those  particular  estates. 

Work  on  Estates.  After  an  interval  of  from  30  to  42  weeks 
the  coolies  who  had  been  examined  at  the  ports  of  entry — or  as  many 
of  them  as  could  be  traced — were  followed  to  the  several  estates 
to  which  they  had  gone  to  work.  Fourteen  estates  were  thus  vis- 
ited, and  264  coolies  were  identified  and  re-examined  for  signs  of 
anemia,  malaria,  and  hookworm  disease.  Statistics  were  tabulated 
with  reference  to  both  those  who  had,  and  those  who  had  not,  been 
treated  for  hookworm  infection  at  Port  Swettenham,  and  who,  sub- 
sequently (on  the  estate)  either  did  or  did  not  show  signs  of  malaria. 
This  work  of  investigation  on  the  estates  was  begun  about  the  middle 
of  June,  1916,  and  was  concluded  about  the  end  of  August,  1916,  a 
period  of  approximately  two  and  one-half  months. 

The  re-examination,  on  the  estates,  of  cases  treated  at  Port  Swet- 
tenham showed  that  the  benefit  of  treatment  for  hookworm  disease 
was  nullified  on  the  flatlands  estates,  as  a  result  of  re-infection,  but 
that  on  the  hilly  estates  the  beneficial  results  of  treatment  were 
maintained,  provided  the  coolies  did  not  contract  malaria.  This 
disease  was  found  to  be  the  chief  anemia-producing  factor  on  these 
latter  estates,  while  hookworm  infection  was  found  to  be  relatively 


2O  INTERNATIONAL   HEALTH    BOARD 

unimportant.     The  contrary  proved  to  be  true  on  the  estates  located 
on  flat  coastal  plains. 
Work  among  School  Children,  Mine  Laborers,  and  Others. 

In  addition  to  the  work  of  investigation  carried  on  among  coolies  at 
detention  camps  and  on  estates,  the  Commission  conducted  a  num- 
ber of  special  studies  in  the  Federated  Malay  States  among  children 
in  schools,  laborers  in  mines,  patients  in  hospitals,  inmates  of  prisons, 
and  night-soil  coolies. 

Fifty-eight  children  were  treated  at  the  Convent  School  at  Kuala 
Lumpur.  These  children  lived  under  fairly  constant  conditions, 
were  well  nourished,  received  good  care,  and  in  their  surroundings 
were  comparatively  free  from  exposure  to  malaria  or  hookworm 
infection.  They  were  only  lightly  infected  with  the  latter.  No 
definite  relationship  was  established  between  the  duration  of  resi- 
dence and  the  number  of  worms  harbored. 

Two  Malay  schools  for  boys  and  one  for  girls  were  visited  and  the 
children  examined — 83  boys  and  40  girls.  Two  of  the  three  schools, 
one  for  boys  and  one  for  girls,  were  located  at  Kampong  Bharu,  a 
suburb  of  Kuala  Lumpur.  The  surroundings  of  these  schools 
rather  favored  malaria  and,  as  there  was  not  a  little  pollution  of  the 
soil,  there  were  plenty  of  opportunities  for  direct  exposure  to  hook- 
worm infection.  There  was  evidence  of  association  between  worm- 
count  and  hemoglobin  content  whenever  the  number  of  worms 
harbored  was  above  150. 

Work  among  Night-Soil  Coolies.  For  purposes  of  compara- 
tive study,  35  coolies  employed  on  the  public  roads  of  Kuala  Lumpur 
and  90  coolies  engaged  in  collecting,  transporting,  and  burying  night 
soil  were  examined.  Most  of  these  laborers,  particularly  those  in 
the  latter  group,  belonged  to  the  pariah  class  of  Tamils.  Both  groups 
were  infected  with  malaria  and  hookworm  disease.  Naturally,  the 
night-soil  coolies  were  directly  exposed  to  hookworm  infection,  and 
examination  showed  that  they  had  a  high  incidence  of  Necators,  as 
well  as  a  high  incidence  of  Ancylostomes  derived  from  the  feces  of 
Chinese.  Duration  of  exposure  to  infection — that  is,  the  length  of  the 
period  during  which  the  laborers  were  employed  at  this  kind  of  work 
— bore  a  direct  relation  to  the  number  of  Ancylostomes  harbored. 

Work  among  Laborers  in  a  Tin  Mine.  The  Commission  visi- 
ted a  tin  mine  and  examined  two  hundred  workers  in  an  attempt  to 
discover  the  degree  of  hookworm  infection  present,  and  to  determine 
its  effect  on  the  efficiency  of  the  Chinese  laborers  employed  in  both 
surface  and  underground  workings.  It  was  not  easy  to  get  at  the 
facts.  The  mine  was  operated  by  laborers  under  a  contract  which 
left  them  free  to  work  as  much  or  as  little  as  they  pleased.  At  the 
end  of  each  shift  they  were  paid  by  a  headman  for  whatever  they  had 
done.  Under  these  circumstances  there  was  very  little  co-operation. 

Regarding  the  data  obtained,  anemia  was  not  found  to  be  present 
in  any  marked  degree.  The  general  condition  of  the  workers  was 


EXTENT   OF   THE    INVESTIGATION  21 

good;  the  ulcers  which  many  of  them  had  were  probably  occupational 
in  origin.  A  comparison  of  these  mine  workers  with  a  group  of 
coolie  prisoners  in  Taiping  Jail  showed  that  there  were  some  in 
the  jail  who  had  lower  hemoglobins  than  those  who  worked  in  the 
mine.  Probably  the  explanation  is  that  the  less  efficient  are  elim- 
inated from  the  mines,  while  both  the  more  efficient  and  the  less 
efficient  are  to  be  found  in  the  jail.  Comparative  tests  indicated 
that  the  average  hemoglobin  percentage  among  underground  work- 
ers was  slightly  less  than  among  the  surface  workers.  Examination 
of  the  stools  showed  a  slightly  higher  percentage  of  hookworm  infec- 
tion among  the  former  than  among  the  latter.  There  were  very  few 
cases  of  either  malaria  or  dysentery,  but  all  such  cases  showed  a 
lower  hemoglobin  average  as  a  result. 

Work  among  Prisoners  and  Patients.  At  Taiping  Jail,  393 
prisoners  were  clinically  examined  during  the  month  of  August,  1916, 
and  354  were  chosen  for  treatment.  Dysentery  was  found  to  be  a 
decided  factor  in  producing  anemia.  There  was  no  opportunity  for 
hookworm  infection  either  in  the  prison  or  by  means  of  the  latrines 
connected  with  the  prison. 

At  the  District  Hospital  at  Kuala  Lumpur,  a  charitable  institu- 
tion, 588  patients  were  examined  for  plasmodia  in  the  blood,  and  524 
for  ova  in  the  stools.  Special  groups  of  Europeans,  Eurasians,  Sikhs, 
Chinese,  Japanese,  and  Tamil  men  and  women  were  treated  here  and 
at  the  General  and  European  Hospitals.  At  the  Victoria  Institu- 
tion, a  school  for  boys,  500  students  were  examined. 

Control  Investigation  in  Java  and  the  Fiji  Islands.  Be- 
sides these  visits  made  by  the  Commission  to  a  number  of  places  in 
several  different  localities  of  the  Federated  Malay  States,  one  mem- 
ber of  the  Commission  spent  a  month  on  the  island  of  Sumatra  inves- 
tigating methods  of  treating  hookworm  disease.  Afterward,  this 
same  member  visited  the  island  of  Java,  and  for  four  months  studied 
hookworm  infection  both  with  and  without  malarial  complications, 
among  the  natives  in  urban  as  well  as  rural  sections.  Then,  for  the 
purpose  of  checking  up  the  findings  of  the  Commission  in  Java, 
Sumatra,  and  the  Federated  Malay  States,  two  members  visited  an 
island  in  the  Fiji  Archipelago  (Viti  Levu)  known  to  be  entirely  free 
from  malaria. 

In  the  course  of  its  investigations  the  Commission  microscopically 
examined  the  feces  of  3,776  Tamils,  Chinese,  Malays,  Bengalese, 
Singalese,  and  Eurasians,  and  found  that  of  this  number  87.8  per 
cent  were  positive  for  hookworm  ova.  (See  Table  6,  page  125.) 
The  labors  of  the  Commission  extended  over  a  period  of  twenty-five 
months. 


CHAPTER   IV 


METHODS  OF  EXAMINATION 

Two  Principal  Methods.  The  actual  presence  of  hookworms  in 
a  person  suspected  to  be  infected  may  be  determined  either  by  micro- 
scopic examination  of  the  feces  for  ova  (smear  and  centrifuge 
methods),  or  by  vermicidal  treatment  and  the 
recovery  of  worms  expelled.  The  latter  is  the 
more  accurate  method.  The  present  chapter 
will  be  devoted  to  an  exposition  of  these 
methods  of  examination  for  determining  in- 
fection; in  the  next  chapter  the  technique  of 
treatment,  as  tested  by  experience,  will  be 
discussed  in  detail. 


EXAMINATION   OF   FECES    FOR    OVA 


Smear  Method.  There  are  two  methods 
of  examining  feces  for  hookworm  ova — the 
smear  method,  and  the  centrifuge  method. 
The  smear  method  as  described  below  was 
used  most  often  in  the  course  of  the  Com- 
mission's investigations  because,  owing  to  its 
simplicity,  it  enables  the  microscopist  to 
make,  with  the  least  expenditure  of  time, 
an  estimate  of  the  number  of  ova  in  each 


Fig.  18. — Respective 
merits  of  microscopic 
examination  and  med- 
ication as  means  of 
revealing  hookworm 
infection.  All  races. 
(Table  6) 


specimen. 

Microscope  slides  (2"  x  3")  are  prepared  in 
advance.  Each  slide  is  labeled  so  as  to 
correspond  with  the  number  given  to  the 
particular  specimen  under  examination.  An 
area  is  inclosed  on  the  upper  surface  of  the  slide  by  means  of  a 
line  drawn  with  a  grease  pencil.  A  mixture  of  glycerine  and  sat- 
urated solution  of  NaCl,  in  equal  parts,  is  dropped  into  this  area 
along  with  a  portion  of  feces  which  has  been  diluted  with  water  and 
thoroughly  stirred,  to  insure  a  fairly  uniform  distribution  of  the  ova 
throughout  the  mass.  Experience  showed  that  the  best  results  are 
to  be  obtained  when  the  amount  of  feces  is  so  large  as  almost  to 
overflow  the  greased  lines,  and  yet  not  so  large  as  to  be  too  opaque 
for  microscopic  examination. 

22 


Fig.  20. — Night-soil  disposal.  Filling  the  trenches.  Sur- 
face contaminated  with  feces,  and  one  has  to  walk  with 
the  greatest  circumspection.  A  guard  is  placed  nightly 
to  prevent  the  Chinese  market  gardeners  from  exhuming 
the  buried  night  soil.  The  efforts  of  the  guard  are,  as  a 
rule,  futile 


Fig.     21. — Night-soil    disposal.     Washing    the    buckets. 

The  shore  is  heavily  polluted.     Hookworm  larvae  were 

detected  here 


METHODS   OF   EXAMINATION  25 

Ten  or  twelveof  these  slides,  prepared  by  especially  trained  dressers, 
are  then  placed  on  a  slide-holder  constructed  of  a  thin  board,  and 
brought  to  an  expert  microscopist  for  examination.  The  actual 
examination  of  ova  was  never  intrusted  to  a  subordinate.  Because 
of  the  difference  in  specific  gravity  the  worm  ova  always  rise  to  the 
surface;  then  they  are  readily  recognized.  The  action  of  the  glycerine 
in  clearing  the  fecal  mixture  more  rapidly  than  it  does  the  worm  ova, 
makes  the  ova  especially  conspicuous. 

Centrifuge  Method.  The  centrifuge  method  and  a  modifica- 
tion of  the  centrifuge  method  are  both  used.  As  in  the  case  of 
the  smear  method,  the  centrifuge  process  involves,  first,  mixing  a 
mass  of  fecal  matter  with  water,  according  to  consistency.  The 
mixture  is  then  placed  in  a  test  tube  and  centrifuged,  after  which 
the  supernatant  fluid  is  poured  off.  A  saturated  solution  of  NaCl  is 
added;  or,  if  glycerine  is  available,  a  mixture  of  equal  parts  of  glyc- 
erine and  a  saturated  solution  of  NaCl  is  added  and  thoroughly 
mixed.  Then  the  mass  is  again  centrifuged.  Enough  liquid  is  added 
to  practically  fill  the  tube.  The  ova  are  removed  by  means  of  wisps 
of  cotton,  which  are  mounted  and  examined  under  a  microscope. 

A  modification  of  this  method  of  removing  the  ova — which  was 
also  used — is  the  following.  Wisps  of  cotton,  with  one  end  twisted 
into  a  tail,  or  pieces  of  cotton  string  frayed  at  one  end,  are  prepared 
in  advance.  When  one  of  these  is  placed  in  the  test  tube  the  frayed 
portion  floats  to  the  surface  of  the  fluid.  Two  or  three  drops  of  a  2 
per  cent  solution  of  ordinary  nutrient  agar  are  then  dropped  into  the 
tube.  It  is  better  to  do  this  when  the  melted  agar  is  still  hot.  If 
glycerine  is  not  available,  saturated  solution  of  NaCl  will  answer. 
The  agar  will  float  and  solidify  as  a  disc,  and  the  ova,  rising,  will 
adhere  to  this  disc. 

When  the  tubes,  thus  prepared  and  labeled,  are  placed  in  a  rack 
and  brought  to  the  microscopist,  the  agar  disc  is  lifted  off  without 
difficulty  by  means  of  the  twisted  end  of  the  cotton  wisp.  The 
disc  is  then  placed  on  a  slide,  fecal  surface  uppermost.  A  cover  glass 
is  adjusted  and  pressed  down,  and  the  preparation  is  ready  for  exami- 
nation. Two  discs  may  be  placed  on  one  slide.  It  will  not  be  found 
difficult  to  detect  the  ova,  for  if  they  are  not  found  on  the  surface  of 
the  disc  they  will  be  found  but  very  slightly  imbedded.  It  is  better 
to  examine  these  preparations  before  the  ova  have  had  an  opportu- 
nity to  become  transparent — say  within  an  hour — for  in  a  condition 
of  transparency  they  are  more  difficult  to  detect. 

In  populations  in  which  there  is  a  large  percentage  of  persons 
positive  to  hookworm,  this  method  offers  the  advantage  that  as 
many  as  thirty  cases  an  hour  can  be  examined.  When  a  specimen  is 
found  negative  upon  examination,  further  specimens  can  of  course  be 
obtained  on  subsequent  days,  for  purposes  of  re-examination.  But 
in  a  population  heavily  infected,  such  re-examinations  of  apparent 
negatives  are  not  worth  while.  For  example,  of  the  2,262  cases 
examined  by  the  Commission  at  Port  Swettenham,  64  who  were 


26 


INTERNATIONAL  HEALTH  BOARD 


apparently  negative  were  re-examined;  but  the  results  of  these 
examinations  were  so  slight  as  to  raise  the  total  positive  by  only  1.5 
per  cent.  In  one  of  the  jail  series,  349  cases  were  examined  and  73 
found  to  be  apparently  negative;  but  upon  re-examination  on  subse- 
quent days,  only  11  of  the  73  proved  positive. 

The  reliability  of  feces  examinations  for  ova  can  best  be  determined 
by  comparing  the  percentage  of  positives  thus  obtained  with  the 
percentage  obtained  by  recovering  the  worms  expelled  by  treatment. 
In  the  work  of  the  Commission  the  results  secured  by  the  two  kinds 
of  examinations  were  not  strictly  comparable.  For  instance,  in 
some  cases  dealt  with,  the  group  examined  for  ova  was  not  treated 
at  all;  in  others,  the  treated  cases  had  not  previously  been  examined 
for  ova.  The  feces  examination  usually  included  all  cases  which 
could  be  obtained,  irrespective  of  the  degree  of  anemia;  in  the 
treatment  cases  a  larger  percentage  of  infected  persons  than  of  non- 
infected  were  probably  selected. 

But  in  a  general  way  the  results  from  the  two  groups  are  compar- 
able. The  percentages  of  positives  obtained  by  the  two  kinds  of  ex- 
aminations are  compared  by  races.  (See Table6, page  125:)  Thediffer- 
ence  shown  by  the  totals,  4.6  per  cent,  by  no 
means  fairly  represents  the  superiority  of  the 
treatment  method,  because  the  different  races 
show  different  rates  of  infection,  and  because 
the  numbers  examined  by  the  two  methods 
are  unequal.  Where  a  percentage  of  80  was 
obtained  by  the  method  of  examination  for 
ova  there  is  little  doubt  that  a  percentage  of 
90  or  more  would  have  been  obtained  by 
the  method  of  treatment. 

A  more  exact  comparison  is  obtained  when 
the  same  individuals  who  are  examined  for 
ova  are  subsequently  treated.  In  all,  209 
cases  were  traced  in  which  both  sorts  of  exam- 
inations were  made.  The  results  of  these  ex- 
aminations are  shown  in  Table  7,  page  126. 
Reference  to  this  table  will  show  that  the 
method  of  feces  examination  failed  in  8.1  per 
cent  of  cases  in  which  it  was  later  demonstrated 
that  hookworms  were  present,  and  that  ova 
were  found  in  2.4  per  cent  of  cases  in  which 
treatment  failed  to  detect  any  worms.  Second 
specimens  of  stools  were  available  for  re-ex- 
amination for  ova  in  the  case  of  only  one  of 
the  17  negatives.  The  species  and  number  of 
hookworms  found  in  these  17  cases  are  given 
in  Table  8,  page  127.  It  will  be  seen  that 
3  of  the  17  cases  showed  no  female  worms 
at  treatment,  and  that  12 — or  nearly  three- 


POSITIVE  BY  BOTH  FECAL 

EXAMINATION  $  TREATMENT. 
POSITIVE  BY  TREATMENT  BUT 

NEGATIVE  BY  FECAL  EXAMINATIOfl. 
POSITIVE  BY  FECAL  EXAMINATION 

BUT  NEGATIVE  BY  TREATMENT. 
NEGATIVE  BY  BOTH  FECAL 

EXAMINATION  ^TREATMENT. 


Fig.  22. — Relative  ac- 
curacy of  hookworm  di- 
agnosis by  feces  exam- 
ination, as  indicated  by 
later  recovery  of  worms; 
209  cases  treated  irre- 
spectiveofresultof  fecal 
examination.  (Table  7) 


METHODS   OF   EXAMINATION  27 

fourths — had  two  females  or  less.  Apparently  a  single  thorough 
examination  of  a  stool  fails  only  in  the  case  of  lighter  infection. 

Vermicidal  Treatment  and  Recovery  of  Worms.  The  proced- 
ure followed  in  examination  by  the  method  of  vermicidal  treatment 
and  recovery  of  worms  expelled,  was  practically  the  same  in  all  cases. 
The  people  were  called  together,  physical  and  clinical  examinations 
were  made,  and  representative  cases  were  selected  on  the  basis  of 
hemoglobin  estimations.  On  the  morning  of  the  day  previous  to 
treatment  patients  were  allowed  their  usual  diet;  in  the  afternoon 
they  were  given  some  rice  gruel  and  a  half-pint  of  milk.  At  5:00 
P.M.  a  purgative  was  given — six  drams  of  saturated  solution  of 
magnesium  sulphate,  or  one  ounce  of  sodium  sulphate,  or  one  ounce 
of  castor  oil. 

On  the  morning  of  treatment  all  food  was  generally  withheld, 
although  in  some  cases  a  little  milk  was  permitted.  The  first  dose  of 
the  vermicide  was  given  at  7:00  A.M.;  the  second  and  third  doses 
were  given  at  hourly  intervals  thereafter.  Two  hours  after  the  last 
dose  of  the  vermicide  a  second  purgative  dose  was  administered, 
corresponding  to  the  one  given  the  night  before.  At  12:30  noon, 
the  patients  were  allowed  to  drink  milk,  and  in  the  afternoon  they 
were  given  a  little  rice  or  bread.  The  next  day  they  were  allowed  to 
have  rice  and  curry,  but  vegetables  with  coarse  fibres  were  prohibited 
because  they  interfered  with  the  search  for  worms.  If  a  patient 
remained  constipated  the  purgative  was  repeated.  Patients  were 
enjoined  to  remain  prostrate  for  a  certain  period  after  the  adminis- 
tration of  the  vermicide. 

When  chenopodium  in  the  pure  state  was  given,  it  was  adminis- 
tered in  hard  gelatine  capsules,  which  were  filled  at  the  time  from  a 
standard  pipette.  When  an  emulsion  of  oil  of  chenopodium  in  acacia 
was  given,  it  was  prepared  fresh  on  the  morning  of  the  treatment. 
The  bottle  was  well  shaken  before  each  dose  was  given.  Doses, 
measured  with  a  measuring  glass,  were  given  and  were  followed  by  a 
drink  of  water.  No  separate  purgative  was  required  when  the  emul- 
sion contained  castor  oil.  Thymol  also  was  frequently  used  in  order 
to  test  the  relative  value  of  different  vermicides.  After  the  contents 
were  finely  ground  and  weighed,  capsules  holding  individual  doses 
were  filled  on  the  day  previous  to  treatment. 

Varying  amounts  of  different  kinds  of  medicament  were  given  for  a 
first  treatment;  then,  after  an  interval  of  from  seven  to  ten  days,  a 
second  treatment  was  given — usually  consisting  of  a  full  dose  of 
chenopodium  (3x1  mil).*  The  efficacy  of  the  treatment  was  deter- 
mined by  noting  the  percentage  of  worms  removed,  careful  search 
being  made  of  four  or  more  stools  submitted  by  each  case.  This 
search  for  worms  naturally  proved  to  be  a  tedious  and  laborious 
process. 

Identification  of  Specimens.  At  the  time  of  examination  a 
numbered  metal  disc  was  attached  to  the  wrist  of  each  patient.  At 
the  completion  of  the  treatment  he  was  given  a  vessel  to  which  his 

*One  mil  is  equivalent  to  one  thousandth  part  of  a  milliliter,  i.  e.,  one  cubic 
centimeter. 
3 


28        INTERNATIONAL  HEALTH  BOARD 

name  and  register  number  were  attached.  It  was  always  found  pref- 
erable to  use  enameled  or  agate  vessels.  These  receptacles  were 
thoroughly  washed  and  dried  after  each  using. 

Rigid  military  discipline  was  instituted,  to  avoid  any  possible 
mixing  of  the  feces  of  different  cases.  In  jails,  where  each  person 
was  confined  to  his  own  cell,  it  was  comparatively  easy  to  avoid 
confusion.  In  hospital  wards  the  vessel  was  placed  at  the  patient's 
bedside  and  defecation  was  supervised  by  a  dresser,  who  was  given 
instructions  to  prevent  the  use  by  any  patient  of  a  vessel  not  his  own. 
The  patients  themselves  were  also  given  explicit  instructions.  They 
were  drilled  in  remembering  their  numbers,  and  in  taking  their 
places  in  right  numerical  order  for  treatment  and  for  changing  of 
vessels.  In  the  case  of  children  this  drilling  was  facilitated  by  schemes 
of  rewards. 

The  possibility  of  error  from  mixing  of  stools  was  altogether  elimi- 
nated in  one  series  by  the  device  of  giving  each  patient,  at  the  time 
of  treatment,  a  dose  of  small  glass  beads.  These  beads  differed  in 
color  and  size,  and  only  one  sort  was  given  to  each  patient.  For 
three  or  four  days  patients  continued  to  pass  these  beads,  and  since 
there  was  no  mixing  of  the  different  kinds  of  beads  in  the  stools  it 
is  safe  to  say  that  there  was  no  mixing  of  feces.  In  the  whole  series 
of  treatments  the  degree  of  error  due  to  the  mixing  of  feces  of  differ- 
ent persons  must  have  been  negligible. 

The  procedure  followed  was  to  have  the  feces  brought  to  the 
place  of  examination  twice  daily,  at  about  7:  00  A.M.  and  again  at 
about  2:00  P.M.  Each  patient  usually  brought  his  own  soecimen. 
When  the  patients  entered  the  laboratory,  the  numbers  on  their 
wrists  and  on  the  vessels  were  compared  and  checked,  and  a  slip  of 
paper  with  the  same  number  was  placed  in  the  vessel  with  the  feces. 
All  patients  then  received  clean  vessels,  properly  numbered.  A 
record  was  kept  of  persons  who  brought  no  stools,  and  an  additional 
purge  was  given  to  them  when  it  was  considered  necessary  and 
desirable. 

Washing  of  Stools.  A  regular  routine  was  followed  in  the 
washing  of  stools.  Those  that  were  soft  or  fluid  could  be  washed  at 
once;  those  that  were  more  compact  had  to  be  mixed  with  water  and 
stirred  until  soft.  When  a  tap  was  available,  the  washing  was  done 
in  the  sink  beneath  it.  Usually,  however,  there  was  no  water  piped 
to  the  laboratory,  and  it  was  necessary  to  use  a  stream  siphoned 
through  a  rubber  hose  from  a  large  container  placed  several  feet 
above  the  ground.  The  washing  was  then  done  by  means  of  a  jet  of 
water  played  into  a  large  brass  wire  sieve  (with  a  mesh  of  50  to  an 
inch)  into  which  the  contents  of  the  vessel  had  been  poured. 

In  order  not  to  force  the  worms  through  the  meshes  of  the  sieve, 
it  was  found  advisable  to  use  a  stream  of  moderated  force.  The 
regulation  of  the  stream  was  readily  accomplished  by  means  of  a 
pinch-cock  at  the  lower  end  of  the  hose.  The  operation  was  always 
closely  supervised  so  as  to  prevent  splashing  and  consequent  loss  of 


Fig.  23. — Prisoners  in  Java  jail.     Treatment  squad  chang- 


ing "jerries" 


Fig.  24. — Dr.   Darling  making  the  hookworm  survey  in 
Batavia  jail 


Fig.  25. — Squad    No.    3,    Java    jail.      Spleen    rate,    nil; 
parasite  rate,  21.8%;  hookworm  incidence,  95.8%;  aver- 
age number  of  worms,  54;  average  hemoglobin,  94.6%; 
malaria,  mild 


Fig.  26.— Squad  No.  2,  Java  jail.     Spleen  rate,   70.8%; 
parasite  rate,  12.5%;    hookworm  incidence,  100%;    aver- 
age number  of  worms,  139;   average  hemoglobin,  44.8%; 
malaria,  severe 


METHODS    OF   EXAMINATION  31 

material.  Care  was  also  exercised  to  provide  against  worms  adhering 
to  the  sieve  and  being  carried  from  one  stool  to  another.  After  this 
washing  process,  the  worms,  the  remaining  insoluble  portion  of  the 
stool,  and  the  labeled  slip  were  all  rinsed  into  the  vessel  bearing  the 
number  of  the  patient  whose  stool  had  been  examined. 

The  washed  stool  was  next  distributed  into  photographic  develop- 
ing trays,  a  small  portion  into  each  tray.  A  dark  brown  tray  was 
found  to  furnish  the  best  background  for  the  worms.  These  were 
then  picked  out  with  needles  or  forceps  and  placed  in  properly  num- 
bered petri  dishes  containing  normal  salt  solution.  Frequently  the 
trays  were  examined  and  the  worms  removed  by  assistants;  but  a 
member  of  the  Commission  always  made  a  re-examination,  sometimes 
on  both  a  dark  and  a  light  background.  It  was  possible  for  one  mem- 
ber of  the  Commission  to  inspect  and  check  up  the  work  of  two  or 
more  assistants,  of  course  provided  the  actual  number  of  worms 
which  had  to  be  picked  out  was  not  too  great. 

The  original  numbered  slip  which  served  as  a  label  was  placed, 
number  side  up,  under  the  cover  of  the  petri  dish.  This  paper  slip 
remained  in  direct  contact  with  the  contents  of  the  stool,  from  the 
time  the  vessels  were  first  received  up  to  the  time  of  the  final  counting 
and  recording  of  the  worms;  it  proved  very  effective  in  preserving 
accuracy.  At  least  four  stools  were  collected  from  each  person.  But 
the  number  that  had  to  be  examined  was  usually  greater  than  that, 
for  the  series  of  washings  in  any  one  case  was  never  considered  com- 
plete until  two  consecutive  negatives  had  been  obtained.  It  is  always 
highly  important  to  expel  the  last  worms,  because  the  proportions 
of  different  species  and  sexes  vary  according  to  the  interval  following 
treatment. 

Finally,  the  excess  salt  solution  was  drained  from  the  petri  dishes; 
the  worms  were  then  killed  by  flooding  these  dishes  with  boiling 
alcohol  (70  per  cent).  As  Lane  has  pointed  out,  when  scalded  the 
worms  become  rigid  and  assume  the  shapes  that  are  characteristic  of 
the  different  species.  Differentiation  is  thus  rendered  comparatively 
easy  and  the  worms  can  be  rapidly  counted.  The  Commission  kept 
careful  records  of  the  numbers  and  sexes  of  the  different  species 
expelled  and  recovered. 


CHAPTER  V 


METHODS  OF  TREATMENT 

Routine  Treatment.  The  routine  technique  of  treatment  was, 
first,  to  give  one  treatment  with  the  remedy  which  was  to  be  tried, 
and  then  to  give  chenopodium  in  the  subsequent  treatments.  The 
first  treatment  was  called  the  trial  treatment,  and  the  second  treat- 
ment was  called  the  test  treatment.  Experience  convinced  the  Com- 
mission that  this  second  treatment  should  never  be  given  until  after 
the  lapse  of  one  full  week.  After  the  first,  or  trial,  treatment  the 
worms  expelled  were  collected  and  counted. 

One  week  or  more  after  the  second,  or  test,  treatment  the  stools 
were  examined  for  ova,  and  if  they  were  still  found  to  be  positive  other 

treatments  were  given  until  they 
proved  negative.  Next,  the 
number  of  worms  expelled  was 
counted,  and  it  then  became  pos- 
sible to  determine  both  the  per- 
centage of  the  worms  removed 
by  the  first  treatment  and  the 
number  of  cases  actually  cured. 
By  way  of  preparation  for 
treatment  the  patients  in  a  cer- 
tain series  of  experiments  (at 
Taiping  Jail)  had  their  accus- 
tomed fare  at  11:00  A.M.,  but 
at  the  afternoon  meal — which 
was  usually  served  at  3:00  P.M. 
— they  were  given  only  soft  rice 
gruel.  At  4:00  P.M.  a  concen- 
trated solution  of  magnesium 
sulphate  (one  ounce  of  the  salt) 
was  given  as  a  purge.  On  the 
following  morning  the  patients 
had  milk  instead  of  their  ordi- 
nary meal,  and  then  the  treat- 
ment was  given.  The  last  dose 
of  medicine  was  followed,  after 


^  PERCENTAGE  REMOVED  BY  TRIAL  TREATMENTS  TOTAl  NEGATORS  HARDOffi 
•  Pf  RCENIAGE  RE  MOVED  BY  TRIAL  TREATM  ENT  OF  TOTM.  ANCKIOSIWES  HARM) 


Fig.  27. — Comparative  effect  of 
thymol  and  chenopodium  on  two 
species  of  worms.  (Table  9) 


an  hour's  interval,  by  a  second  purge  of  magnesium  sulphate  (one 
ounce).  After  the  purge  was  given,  the  prisoners  were  again  locked  up 
in  their  cells,  kept  away  from  work,  and  allowed  out  only  for  exercise. 
The  stools  were  collected  at  2:00  P.M.  on  the  day  of  the  treat- 
ment, and  at  7:00  A.M.  and  2:00  P.M.  on  the  two  days  immediately 
following.  These  stools  were  washed  and  examined  for  worms  until 
72  hours  had  expired,  and  usually  during  this  period  six  stools  per 

32 


METHODS   OF   TREATMENT 


33 


case  were  obtained.  However,  if 
at  the  end  of  48  hours  any  patient 
had  two  consecutive  stools  with 
no  worms  in  them  he  was  re- 
leased, always  provided  that  at 
least  four  stools  had  been  washed 
and  examined.  If  at  the  time  of 
any  of  the  regular  routine  wash- 
ings, a  patient  did  not  have  a 
stool,  he  was  immediately  given 
another  saline  purge. 

Relative  Efficacy  of  Various 
Methods   of    Treatment.     A 

considerable  number  of  experi- 
ments (twenty-one  separate  se- 
ries) in  the  administration  of 
vermicides  were  conducted  by 
the  Commission,  in  the  District 
Hospital  at  Kuala  Lumpur  and 
elsewhere.  The  particular  ob- 
ject was  to  reach  a  scientific  con- 
clusion as  to  the  quantitative 
value  and  relative  merits  and 


SSJ  SUPERIORITY  OFCHENOPODIUM  IN  REMOVING 
NECATORS 

•  SUPERIORITY  OF  CHENOPODIUM  IN  REMOVING 
ANCYLOSTOMES 


Fig.  29. — Superior  efficacy  of 
chenopodium,  as  compared  to  thy- 
mol, in  removing  more  resistant 
worm  species.  (Table  11) 


Fig.  28. — Effect  of  full  and  re- 
duced dosages  of  thymol  and  oil  of 
chenopodium  in  expelling  two  species 
of  worms,  trial  treatment.  (Table  10) 

efficacy  of  differently  graduated 
doses  of  chenopodium  and  thy- 
mol for  routine  treatment.  The 
results  of  these  numerous  experi- 
ments can  be  summed  up  in  a 
few  paragraphs. 

Chenopodium  in  small  doses 
proved  to  be  more  efficacious 
than  small  doses  of  thymol; 
also  it  showed  a  satisfactory 
efficacy  in  a  greater  range  of 
doses.  While,  dose  for  dose, 
both  drugs  showed  about 
equal  efficacy  in  removing  Ne- 
cators,  chenopodium  was  quite 
superior  to  thymol  in  remov- 
ing the  more  resistant  species 
of  hookworm,  i.  e.,  Ancylos- 
tomes.  (See  Table  9,  page  128.) 
Chenopodium  also  was  more 
effective  in  removing  other 
worms,  such  as  Ascaris  and 
Trichuris.  There  was  failure  to 
cure  the  patient  (by  removing 


34 


INTERNATIONAL   HEALTH    BOARD 


all  hookworms)  in  23.6  per  cent  of  the  cases  treated  with  thymol, 
but  in  only  7.6  per  cent  of  the  cases  treated  with  chenopodium. 

Better  results  are  obtained  from  chenopodium  when  it  is  given  in 
the  original  form  of  an  oil  than  when  it  is  prepared  as  an  emulsion. 
On  the  other  hand,  better  results  are  obtained  from  thymol  when  the 
drug  is  especiallypreparedinan  emulsion  than  when  it  is  administered 
in  the  form  of  a  powder.  The  explanation  is  that  chenopodium,  a 
penetrating  oil,  on  being  received  into  the  system  is  more  uniformly 
distributed  throughout  the  intestinal  contents  than  is  thymol  when 
given  as  a  relatively  insoluble  powder. 

The  half-maximum  dose  of  chenopodium  (.5  mil  three  times,  or  a 
total  of  1.5  mils)  is,  in  the  experience  of  the  Commission,  the  best 
treatment  as  a  routine  vermicide.  For  while  it  does  not  have  the 
toxic  effects  of  the  full  dose,  it  was  found  that  it  will  in  two  treatments 
remove  about  99  per  cent  of  all  the  worms  present.  A  single  treat- 
ment of  3  mils  of  chenopodium  gave  the  best  results  of  any  single 
treatment  tried;  but  the  90-grain  dose  of  thymol  was  only  slightly 
inferior  in  results.  Both  effected  very  satisfactory  removal  of  worms. 
In  Tables  10  and  11,  pages  129  and  130,  are  indicated  the  effects  of 
varying  dosages  of  these  two  drugs  upon  Necators  and  Ancylostomes. 
Among  the  prisoners  at  Taiping  Jail  further  experiments  in  treat- 
ment were  conducted.  Altogether  393  prisoners  were  treated,  for 

the  most  part  in  groups  of  ten. 
In  addition  to  the  customary 
treatment  with  chenopodium  (3 
mils  in  3  doses  of  1  mil  each) 
and  thymol  (90  grains  in  3 
doses  of  30  grains  each),  a  num- 
ber of  experiments  were  made 
with  beta-naphthol  (20  grains  in 
capsules),  with  eucalyptus  (30 
minims),  with  chloroform  (45 
minims),  and  with  castor  oil  (12 
drams  divided  into  2  doses  of 
6  drams  each).  (See  Table  12, 
page  131.) 

The  cases  of  treatment  were 
chosen  at  random.  In  the  sta- 
tistics no  comparisons  were  made 
between  Chinese,  Tamils,  and 
Malays,  for  the  reason  that 
Chinese  harbor  fewer  worms 
than  either  Tamils  or  Malays, 

Fig.  30.— Efficacy  of  various  ver-  \nd  fo[  th*  further  reaLsont  that 

micides  in  expelling  hookworms  and  the>r    harb°r     *     much     larger 

effecting  cure.     Worms  removed  by  percentage     of     Ancylostomes. 

entire   treatment;    cases   cured   by  Statistics  with  reference  to  the 

trial  treatment.     (Table  12)  relative   efficiencv    of    different 


METHODS   OF   TREATMENT 


35 


drugs  used  in  the  treatment  of 
the  respective  groups  mentioned 
would  be  invalid  because,  as  the 
Commission  discovered  in  the 
course  of  its  investigations,  it  is 
more  difficult  to  obtain  a  high 
percentage  of  worms  expelled 
when  few  worms  are  harbored 
than  when  the  number  of  worms 
is  great;  moreover,  Ancylos- 
tomes  are  much  more  tenacious 
than  Necators,  and  hence  more 
difficult  to  expel.  The  different 
races,  it  must  be  borne  in  mind, 
have  different  worm  formulae. 

The  efficacy  of  chenopodium 
continued  high  even  when  the 
dose  was  reduced  to  one-quarter 
of  the  maximum  dose;  on  the 
other  hand,  the  diminution  of 
the  dose  of  thymol  resulted  in  a 


lilll 


60 
I  50 

u-i 

^40 
§30 

QC 

£20 
10 


• 


Fig.  32. — Worms  expelled  and 
cases  cured  by  two  half-maximum- 
dose  treatments  of  chenopodium,  as 
compared  with  two  20-grain  treat- 
ments of  thymol  in  various  forms. 
(Table  14) 


ItHII     IliUll 


•II    HUN 


WORMS 

23 
CASES 


WORMS 

39 
CASES 


EFFECT    OH 
NECATORS 


WORMS 

n 
CASES 


WORMS 

J9 
CASES 


EFFECT  ON 
ANCYLOSTOMES 


THYMOL    40  GRAINS  EACH  DOSE 
CHENOPODIUM      1.5  MILS  EACH  DOSE 


Fig.  31. — Hookworms  expelled 
by  two  treatments  of  smaller  than 
maximum  doses  of  thymol  and 
chenopodium.  Two  trial  treat- 
ments. (Table  13) 

rapid  falling  off  in  effic'acy. 
Two  treatments  of  the  half- 
maximum  dose  of  chenopodium 
produced  better  results  than  one 
full  maximum  dose;  in  fact,  the 
highest  percentage  of  worms  re- 
moved was  obtained  by  this  treat- 
ment— 99.6per  centof  Necators, 
and  91.6  per  cent  of  Ancylos- 
tomes.  Two  treatments  with  a 
small  dose  of  thymol  did  not  pro- 
duce a  good  summation  of  results. 
Test  votes  taken  clearly  indica- 
ted that  nearly  all  the  patients 
preferred  chenopodium  to  thy- 
mol, as  being  less  unpleasant  to 
take.  For  these  several  reasons, 
thymol  was  deemed  less  suitable 
for  use  in  general  treatments,  and 
particularly  in  the  treatment  of 
children.  (See  Tables  13  and  14, 
pages  132  and  133.) 


INTERNATIONAL   HEALTH    BOARD 


Another  series  of  treatments  (eight  in  number)  was  given  in  order 
to  determine  the  action  and  results  of  eight  different  doses  of  cheno- 
podium.  All  the  patients  were  Chinese,  and  in  all  cases  there  was 
uniform  preparation.  These  experiments  showed  that  3  mils  of 
chenopodium  in  freshly  prepared  capsules,  administered  in  doses  of 
1  mil,  3  times,  at  hourly  intervals,  gave  by  far  the  best  results;  98.9 
per  cent  of  all  the  worms  present  were  removed,  and  in  82.4  per 
cent  of  all  the  cases  treated  cures  were  effected.  (See  Tables  IS  and 
16,  pages  134  and  135.) 

The  superior  efficacy  of  freshly  prepared  hard  gelatine  capsules 
of  chenopodium,  as  compared  with  the  manufactured  soft  capsules, 

was  demonstrated  by  two  series 
of  experiments.  With  one  group 
of  patients  the  manufactured 
capsules  containing  chenopo- 
dium were  used,  but  with  the 
result  that  only  66.4  per  cent 
of  the  worms  present  were  ex- 
pelled. Then  the  chenopodium, 
extracted  from  manufactured 
capsules  which  have  thick, 
tough  gelatine  walls,  was  placed 
in  freshly  prepared  capsules. 
These  were  administered"  to 
another  group,  with  the  excel- 
lent result  that  97.9  per  cent 
of  the  worms  present  were  ex- 
pelled. Care  was  taken  that  all 
the  patients  in  these  groups  re- 
ceived exactly  the  same  diet  and 
exactly  the  same  previous  purga- 
tion. (See  Table  15,  page  134.) 
The  Commission  wished  to 
learn  whether,  in  order  to  get 
satisfactory  results,  it  was  neces- 
sary to  administer  the  chenopo- 


Fig.  33. — Worms  expelled  and 
cases  cured  by  chenopodium  in  vari- 
ous doses.  Single  trial  treatment. 
(Table  15) 


dium  in  three  separate  doses.  Experiments  were  therefore  made 
on  a  series  of  30  cases,  a  single  dose  of  2  mils  being  given.  The  inter- 
esting result  was  that  95.8  per  cent  of  the  total  number  of  worms 
present  were  removed,  and  70  per  cent  of  all  the  cases  treated  were 
cured.  (See  Table  15,  page  134.) 

• 

Relative  Costs  of  Treatment.  An  attempt  was  made  to  esti- 
mate the  relative  costs  of  treatment  by  chenopodium  and  by  thymol. 
Figures  were  preserved  and  tabulated,  based  on  actual  experiments 
made  among  sixteen  different  groups.  At  the  time  of  the  particu- 
lar treatments  mentioned  (February,  1917)  the  price  of  chenopodium 
was  1.84  cents  per  mil,  and  the  price  of  thymol  was  0.15  cent  per 


METHODS   OF   TREATMENT 


37 


grain.  The  most  satisfactory  re- 
sults, as  far  as  the  removal  of 
worms  was  concerned,  were  ob- 
tained with  one  treatment  of 
chenopodium — 3  mils,  adminis- 
tered in  3  doses,  each  dose  con- 
sisting of  1  mil.  On  this  basis, 
the  cost  per  individual  for  the 
chenopodium  treatment  there- 
fore amounted  to  5.52  cents. 
Proper  comparison  of  costs  can 
be  made  only  by  using  the  dos- 
age of  thymol  which  proved  to 
be  most  effective  in  removing 
worms,  viz.,  one  treatment  con- 
sisting of  90  grains,  administered 
in  3  doses  of  30  grains  each.  On 
this  basis  the  cost  of  the  thymol 
treatment  per  individual  was  13.5 
cents.  It  will  therefore  be  seen 
that  treatment  with  chenopodi- 
um costs  less  than  one-half  as 
much  as  treatment  with  thymol. 


Fig.  35. — Cost  of  thymol  and 
chenopodium,  with  comparative 
efficacy  based  on  worms  expelled. 
(Table  18) 


Fig.  34. — Worms  expelled  and 
cases  cured  by  thymol  in  large  doses. 
Single  trial  treatment.  (Table  16) 

These  data  involve  a  considera- 
tion that  is  of  importance  eco- 
nomically when  mass  treatment  of 
populations  numbering  millions 
is  contemplated.  (See  Table  18, 
page  138.) 

After-effects  of  Treatment. 
Observations  were  made  with  re- 
spect to  the  after-effects  of  treat- 
ment, such  as  dizziness,  unsteadi- 
ness of  gait  (drunkenness),  inabil- 
ity to  rise,  semi-comatose  state, 
tingling  of  hands  and  feet,  deaf- 
ness, burningin  the  stomach,  and 
headache.  Allof  these,  except  the 
last  two,  were  more  commonly 
complained  of  after  the  use  of 
chenopodium  than  after  treat- 
ment with  any  other  vermicide. 
(See  Table  19,  page  139.)  Streaks 
of  blood  in  the  vomitus  were 
occasionally  noted.  These  were 
probably  due  to  the  strain  of 
vomiting,  whether  thymol  or 


INTERNATIONAL   HEALTH    BOARD 


chenopodium  was  used.  Giddiness  was  always  experienced,  usually 
after  the  second  dose,  by  all  persons;  it  was  more  marked  among  men 
than  among  women.  Not  infrequently  all  the  men  would  be  lying 
down,  giddy,  after  the  third  dose,  while  the  women  would  be  sitting 

up,  talkative  and  cheerful.  The 
manifestation  of  this  minor  phy- 
siological symptom  was  always 
to  be  desired,  since  it  was  in- 
dubitable evidence  that  the  drug 
had  been  taken. 

Experience  with  regard  to  the 
after-effects  varied  among  the 
people  treated  in  the  different 
localities.  The  more  severe 
symptoms  were  very  rarely 
complained  of  by  the  dessa 
people  in  Java,  who  received 
treatment  with  chenopodium 
as  an  emulsion.  For  example, 
only  one  out  of  175  persons 
so  treated  complained  of  deaf- 
ness. On  the  other  hand,  in  a 
jail  where  the  prisoners  were 
treated  with  the  raw  oil  of 
chenopodium  in  capsules,  from 
16  to  20  per  cent  complained  of 
deafness. 

In  a  hospital  ward  it  was 
somewhat  difficult  to  ascertain 
the  degree  of  discomfort  experienced,  for  each  person  was  very  likely 
to  answer  a  question  just  as  the  one  before  him  had  answered  it. 
In  order  that  this  possibility  of  error  might  be  obviated,  all  the 
men  on  one  side  of  the  ward  would  be  given  magnesium  sulphate 
and  all  the  men  on  the  other  side  would  be  given  castor  oil,  both 
before  and  after  the  treatment  with  chenopodium.  It  was  observed 
that  giddiness  and  deafness  were  more  often  experienced  by  the  men 
who  had  been  given  castor  oil  than  by  those  who  had  been  given 
magnesium  sulphate.  At  the  time  of  the  "parade,"  when  each  man 
had  to  rise,  pick  up  his  pot,  walk  out  to  the  veranda,  and  exchange 
the  pot  for  a  fresh  one,  it  was  quite  noticeable  that  the  castor  oil 
group  contained  the  men  who  were  suffering  more  severely  from  the 
effects  of  the  drug.  Sometimes  they  were  unable  to  walk,  or  even 
to  rise  from  their  beds,  without  assistance. 

Among  the  immediate  after-effects  of  treatment  by  vermicidal 
drugs  may  be  noted  the  effect  on  the  hemoglobin  of  the  patients.  A 
temporary  fall,  or  net  loss,  was  observed  after  treatment  by  cheno- 
podium when  the  normal  hemoglobin  of  patients  was  from  61  to  70 
per  cent.  Similarly  a  net  loss  in  erythrocytes  was  observed  after 


3   7 

UJ         ' 

z 

u-      fr 

25 

o     5 

u. 

o      . 

<r> 

UJ        _ 

3     3 

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& 

I.I 

UJ         ' 
0 

$     ° 

0.0 

0.0 

o.o  o.o 

o.o  P^ 

5 

2 

[s 

UJ 

THYMOL 
40  GRAINS 

HENOPODIU 
0.75  MILS 

THYMOL 
60  GRAINS 

HENOPODIU 
1.5  MILS 

THYMOL 
90  GRAINS 

HENOPODIU 
3.0  MILS 

u 

0 

o 

•  CHENOPODIUM 

Fig.  36. — After-effects  of  thymol 
and  chenopodium  —  incidence  of 
deafness.  (Table  19) 


METHODS   OF   TREATMENT 


39 


treatment  by  chenopodium  when  the  patient's  hemoglobin  normally 
registered  80  per  cent  and  over.  In  anemia  cases,  on  the  contrary, 
the  increase  of  hemoglobin  or  erythrocytes  was  not  interfered  with 
by  the  administration  of  chenopodium.  In  fact,  both  would  mount 
almost  immediately  after  treatment,  and  within  a  week  would  return 
to  normal.  Relapse  cases  of  malaria  following  the  administration 
of  chenopodium  were  examined,  in  order  to  determine  whether  or 
not  the  relapse  might  be  due  to  an  attack  of  malaria  superinduced 
by  the  drug.  No  relationship  of 
cause  and  effect  was  indicated. 

Excretion  of  Chenopodium 
and  Albuminuria  in  the 
Urine.  Investigations  were  un- 
dertaken to  ascertain  the  possi- 
ble toxic  effects  of  chenopodium 
upon  the  kidneys,  as  well  as  the 
amount  of  absorption  and  rate 
of  excretion  of  the  drug.  The 
presence,  or  absence,  of  al- 
bumin in  the  urine  is  determined 
by  the  heat  and  acetic  acid  test. 
To  find  the  presence  of  cheno- 
podium some  urine  is  pipetted 
upon  a  surface  of  concentrated 
nitric  acid.  If  resins  are  present 
a  white  ring,  suggestive  of  albu- 
min, will  form  at  the  junction  of 
the  fluids.  This  ring,  however, 
differs  from  that  which  is  formed 
by  albumin,  in  that  it  forms  at 
a  slightly  higher  level  in  the 
urine  and  is  most  readily  solu- 
ble in  alcohol.  In  concentrated  urine  a  pink  ring  forms  at  the 
junction  of  the  acid  and  the  urine,  and  this  pink  blends  with  the 
white  ring  that  forms  just  above  it. 

In  albuminous  urine  the  rings  caused  by  albumin  and  resin  form 
together,  but  on  the  addition  of  alcohol  a  cloud  due  to  albumin  still 
remains.  Two  or  three  drops  of  absolute  alcohol  are  sufficient  to 
dissolve  the  resin;  but  the  albumin  will  remain  until  the  concentra- 
tion of  alcohol  is  reached,  at  which  time  its  oxidation  by  the  nitric 
acid  takes  place.  Some  attempts  were  made  to  obtain  a  quantitative 
estimate  of  the  amount  of  resin  present;  the  attempts  were  based 
upon  the  finding,  by  titration,  of  the  amount  of  diluted  alcohol  re- 
quired to  dissolve  the  ring.  The  results  of  these  trials,  however, 
were  not  sufficiently  constant  to  be  of  any  value.  No  attempt 
was  made  to  determine  gravimetrically  the  amount  of  resin  present. 

The  fact  that  greater  absorption,  as  shown  by  greater  toxic  symp- 
toms, took  place  when  castor  oil  was  used  as  a  purge  than  when 


Fig.  37. — After-effects  of  thymol 
and  chenopodium  —  incidence  of 
albuminuria.  (Table  19) 


4o 


INTERNATIONAL   HEALTH    BOARD 


salines  were  employed,  was  confirmed  by  the  relative  size  and 
opacity  of  the  rings  present.  The  test  was  made  6  hours  after  the 
castor  oil  had  been  given,  in  doses  of  10  minims,  3  times,  in  soft 
capsules.  The  5  cases  to  which  castor  oil  was  given  were  all 
positive,  and  had  much  heavier  rings  than  the  5  cases  to  which 
magnesium  sulphate  was  administered;  among  the  latter,  2  showed 
no  reaction. 

That  more  absorption  takes  place  with  the  larger  dose  of  cheno- 
podium  (3  mils)  than  with  the  smaller  dose  (1.5  mils)  was  indicated 
by  the  greater  toxic  symptoms  produced,  and  was  confirmed  by 
the  incidence  of  the  reaction  in  the  urine  and  the  opacity  of  the 
rings  obtained.  This  was  substantiated  in  two  series  of  experiments. 
In  one  series,  each  of  26  cases  was  given  l.S  mils  of  chenopodium, 
and  of  that  number  12,  or  46.2  per  cent,  showed  positive  reactions. 
In  the  other  series,  each  of  86  cases  was  given  3  mils  of  chenopodium, 
and  of  that  number  70,  or  81.4  per  cent,  showed  positive  reactions. 
The  rings  were  much  heavier  in  the  second  series  than  in  the  first. 
That  the  excretion  of  chenopodium,  particularly  the  resinous  part, 
was  slow  (sometimes  not  being  completed  in  five  days)  was  also 
shown  by  a  series  of  experiments.  The  length  of  time  during  which 
the  reaction  lasts  in  the  urine  was  determined  in  a  series  of  12  cases, 
each  of  which  was  treated  with  3  mils  of  chenopodium.  In  7  of 
these  cases  a  reaction  was  obtained  for  as  long  as  126  hours  after 
the  administration.  In  5  of  the  7  cases  no  albumin  was  revealed 

by  the  boiling  test  throughout 
the  observations — which  were 
made  twice  daily — and  hence  no 
difficulty  was  presented  in  the 
determination  of  the  presence 
or  absence  of  resins.  The  other 
2  cases  did  develop  albumin, 
but  the  presence  of  resin  was 
inferred  from  a  partial  solution 
of  the  ring  formed. 

When  the  severe  toxic  symp- 
toms, such  as  coma  and  deaf- 
ness, occurred  they  generally 
were  evident  after  the  second 
treatment.  In  the  earlier  part 
of  the  work  of  the  Commission, 
the  second  treatment  was  given 
on  the  fourth  day,  in  order  that 
the  patients  might  be  released 
within  a  week.  But  the  results 
just  indicated  as  to  excretion 
made  it  clear  that  this  proced- 
Fig.  38. — After-effects  of  thymol  ure  was  not  advisable.  There 
and  chenopodium— deaths.  (Table  19)  was  always  the  danger  that  the 


90 
80 
70 
60 
£     50 

5    40 
u 

0    30 
u. 
o    20 

§    '0 

i      0 

z 

0 

0 

0       0 

0       2 

THYMOL 

40  GRAINS 

CHENOPODIUM 
0.75  MILS 

THYMOL 
ZQ  GRAINS 

CHENOPODIUM 
1.5  MILS 

X 

§<°d 
Hog10 

*S 

•1  CHENOPODIUM 

METHODS   OF   TREATMENT 


second  dose  might  produce  toxic  effects  by  accumulation,  if  given 
before  all  the  drug  from  the  first  treatment  had  been  excreted. 

Although  no  deafness  or  coma  occurred  after  administration  of  the 
lower  doses  of  chenopodium  (1.5  mils),  it  is  to  be  noted  that  the  high- 
est dose  of  chenopodium  (3  mils)  occasionally  produced  these  toxic 
effects  on  the  nervous  system.  With  even  the  highest  doses  of  thy- 
mol, on  the  other  hand,  no  serious  toxic  symptoms  were  noted — 
nothing  more  than  giddiness. 

Among  the  after-effects  of  treatment  by  chenopodium,  there  was 
one  case  of  exacerbation  of  symptoms  of  dementia  praecox.  Only 
two  cases  of  death  occurred  as  the  result  of  treatment,  and  in  both 
of  these  cases  full  chenopodium  treatments  had  been  given  within 
four  days.  After  these  two  fatal  instances,  and  in  all  the  later  work 
of  the  Commission,  the  second  treatment  was  never  administered 
until  an  interval  of  at  least  one  week  had  elapsed. 

Incidence  of  Vomiting.  In  some  of  these  experiments  there 
was  vomiting  after  the  first  treatment  only;  in  some,  after  the  second 
treatment  only;  in  some,  after 
both  treatments;  and  in  some, 
after  neither.  When  vomiting 
occurred  it  usually  took  place 
directly  after  the  second  purge 
was  administered,  and  after  the 
second  dose  of  vermicide.  The 
percentage  of  worms  found 
and  removed,  both  Ancylos- 
tomes  and  Necators,  varied  con- 
siderably in  the  different  series. 
This  difference  in  the  relative 
efficiency  of  the  several  doses 
was  probably  due,  at  least  in 
part,  to  the  vomiting. 

Strong  peppermint  lozenges 
were  sometimes  given  in  order  to 
prevent  this  vomiting  if  possible. 
When  there  was  such  vomiting 
the  drug  was  usually  repeated; 
not  infrequently  the  vomitus 


Fig.  39. — After-effects  of  thymol 
and  chenopodium  —  incidence  of 
vomiting.  (Table  19) 


contained  portions  of  the  ver- 
micide. The  amount  of  vom- 
iting varied  considerably  and 
interfered  not  a  little  with  the  efficiency  of  the  treatment.  It  is 
quite  possible  that  this  reaction  may  have  been  due  to  the  taking 
of  food  secretly  obtained,  or  it  may  have  been  due  to  other  and 
unknown  causes.  A  certain  amount  of  vomiting  is  always  to  be 
expected  in  the  treatment  of  cases  not  under  absolute  control. 

At  Taiping  Jail,  in  the  course  of  the  experiments  performed  there, 
the  dose  of  chenopodium  which  caused  vomiting   resulting  in  loss 


INTERNATIONAL   HEALTH    BOARD 


of  efficiency  was  not  actually 
reached,  although  3  mils  were 
given.  But  in  the  experiments 
at  the  District  Hospital  at 
Kuala  Lumpur,  46.9  per  cent 
of  vomiting  occurred  with  loss 
of  efficiency  at  a  dosage  of  2.8 
mils.  The  heavier  doses  of 
thymol  (120  grains  and  above) 
removed  fewer  worms  than  the' 
lighter  doses,  because  the  vom- 
iting that  occurred  reduced  the 
amount  of  drug  retained  in  the 
stomach  to  considerably  below 
the  quantity  required  for  the 
efficient  removal  of  worms. 

Experiments  with  Purges. 

In  order  to  determine  what 
effect,  if  any,  the  kind  of  purge 
used  had  upon  the  value  of  the 
treatment,  a  series  of  cases  were 
treated  in  which  the  purge  ad- 
ministered was  varied.  To  one 


29  WORMSX97 WORMS)  107 WORMS)  62 WORMS) 


Fig.  41. — Results  obtained  by 
varying  diet  and  omitting  initial 
purge  in  treating  hookworm  disease 
with  chenopodium.  Trial  treatment. 
(Table  21) 


Fig.  40. — Experiments  with  vari- 
ous purges  in  chenopodium  treat- 
ment. (Table  20) 

group, compound  mixtureof  sen- 
na (2  oz.)  was  given;  to  another, 
castor  oil  (1-J-  oz.);  to  another, 
magnesium  sulphate  (1  oz.);  and 
to  another,  calomel  (4  gr.).  If 
these  experiments  proved  any- 
thing, they  proved  that  there  is 
little  or  no  choice  among  the 
several  purges,  with  respect  to 
value  and  efficiency.  (See  Table 
20,  page  141.) 

Diet.  The  standard  routine 
diet  established  consisted  of  rice 
and  gruel  (kunji)  on  the  after- 
noon previous  to  treatment,  and 
milk  on  the  morning  of  treat- 
ment. This  diet  gave  by  far  the 
best  results.  It  was  adopted 
only  after  a  series  of  cases  were 
treated,  with  the  diet  varied. 
Some  of  the  groups  in  the 
series  received  previous  purga- 
tion, and  some  received  none. 
(See  Table  21,  page  142.) 


Fig.  42. — Hookworm  patient,  just  before  being  discharged 
from  Kuala  Lumpur  hospital.    Showing  good  physical  con- 
dition after  removal  of  604  hookworms 


Cu 
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CHAPTER  VI 


FINDINGS     CONCERNING    HOOKWORM 
INFECTION 

Work  at  Port  Swettenham.  At  Port  Swettenham  the  Commis- 
sion examined  the  stools  of  2,262  persons,  of  whom  1,736  were  men, 
384  were  women,  and  142  were  children  under  12  years  of  age.  Of 
this  total  number  examined,  2,188,  or  96.7  per  cent,  were  found  to  be 
positive  for  hookworm  ova,  but  inasmuch  as  stools  for  second  and 
third  examinations  were  obtained  from  only  45  of  the  74  cases  found 
to  be  negative,  it  is  perhaps  reasonable  to  assume  that  the  actual 
percentage  was  nearer  99  per 
cent  than  96.7  per  cent.  (See 
Table  22,  page  143.) 

Relation  between  Patient's 
Age  and  Degree  of  Infection. 

Examination  of  the  stools  of 
children  under  twelve  years  of 
age  showed  clearly  that  a  high 
rate  of  infection  occurs  very 
early  in  life,  and  that  it  pro- 
gresses rapidly  until  the  average 
percentage  for  adults  is  reached. 
These  conclusions  with  reference 
to  the  relation  between  age  and 
hookworm  infection  are  based 
upon  the  analysis  of  results  ob- 
tained from  experiments  among 
persons  of  twelve  years  and 
under.  (The  data  are  presented 
in  Table  23,  page  144.) 

Vulnerability  of  Worms  to 
Vermicide  in  Relation  to 
Species  and  Sex.  The  Com- 
mission found  reasons  for  be- 
lieving that  the  various  kinds  of  worms  differ  in  their  resistance  to 
a  given  dose  of  vermicide — that  Necators  are  less  resistant  than 
Ancylostomes,  and  that  males  in  each  species  are  less  resistant  than 
females.  This  resistance  to  vermicide  was  thought  to  vary  with 
species  and  sex,  increasing  as  the  size  of  the  worm  increases.  In 
order  that  this  theory  might  be  verified,  a  sfudy  was  made  of  a 
series  of  cases  in  which  chenopodium  was  used  as  the  vermicide. 

In  the  first  treatment,  the  total  number  of  worms  removed  was 
4,296,  of  which  number  3,871,  or  90.1  per  cent,  were  Necators  and 

47 


|  60 

iso 


20 


1 

I    I  I 

II   II  II 

II   II  II 

II   II  II 

II   II  II 

HII  II 

II  II 


2?62 

EXAMINED 


BOTH 
SEXES 


1736 

EXAMINED 


MEN 


EXAMINED 


WOMEN 


142 

EXAMINED 


CHILDREN 
UNDER 
TWELVE 


Fig.  48. — Results  of  examinations 
for  hookworm  disease  at  Port 
Swettenham.  (Table  22) 


48 


INTERNATIONAL   HEALTH    BOARD 


425,  or  9.9  per  cent,  were  Ancy- 
lostomes.  Of  the  3,871  Neca- 
tors  removed,  it  was  found  that 
1,897,  or  49  per  cent,  were  fe- 
males and  1,974,  or  51  per  cent, 
were  males.  Of  the  425  Ancy- 
lostomes  removed,  202,  or  47.5 
per  cent,  were  females,  and  223, 
or  52.5  per  cent,  were  males. 

In  the  second  treatment,  the 
total  number  of  worms  removed 
was  217,  of  which  number  108, 
or  49.8  per  cent,  were  Necators, 
and  109,  or  50.2  per  cent,  were 
Ancylostomes.  Of  the  108  Ne- 
cators removed,  70,  or  64.8  per 
cent,  were  females,  and  38,or35.2 
per  cent,  were  males.  Of  the  109 
Ancylostomes  removed,  93,  or 
85.3  per  cent,  were  females,  and 
16,  or  14.7  per  cent,  were  males. 

In  the  third  treatment,  the 
total  number  of  worms  removed 
was  39;  of  that  number,  19,  or 


Fig.  49. — Hookworm  infection 
rates,  by  age  groups,  for  children  less 
than  twelve  years  old.  Examinations 
at  Port  Swettenham.  (Table  23) 


100 

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f, 
fj 

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60 

£ 

• 

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8 

t- 

| 

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0     |_           A0 

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1 

- 

0     lO 

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1 

. 

a 

a.  a 

i 

E 

§ 

<  i      o 

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£  1 

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i 

s 

S  "» 

WORMS  Z  199 
-  ?097 

11 

X 
OC    t 

s 

1  ' 

£ 
g    ' 

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Z 
a.     i 

X 

•PECIES 

SEX 

SPttIB 

SEX 

SPECIES 

SEX 

WORMS 
REMOVED  BY 
FIRST 
TREATMENT 

WORMS 
REMOVED  BY 
SECOND 
TREHTMENT 

V/CRMS  REMOVED 
BY  THIRD  AND 
SUBSEQUENT 
TREATMENTS 

••SPFCIES|NECATORS         SW"ALE 
ED       tU"  I  ANCYLOSTOMES  ^al  FEMALE 

Fig.  50. — Vulnerability  of  worms 
in  relation  to  species  and  sex. 
(Tables  24  and  24A) 


48.7  per  cent,  were  Necators, 
and  20,  or  51.3  per  cent,  were 
Ancylostomes.  Of  the  19  Neca- 
tors removed,  16,  or  84.2  per 
cent,  were  females,  and  3,  or  15.8 
per  cent,  were  males.  (See Tables 
24  and  24A,  pages  145  and  146.) 
In  the  first  treatment,  as  has 
been  stated,  slightly  over  90  per 
cent  of  the  worms  removed  were 
Necators  and  only  slightly  under 
10  per  cent  were  Ancylostomes, 
and  after  a  later  treatment  the 
Ancylostomes  predominated  and 
steadily  increased  in  proportion, 
while  the  Necators  as  steadily 
diminished  in  proportion.  These 
data  indicate  that  the  Necators 
succumb  more  readily  to  the  first 
treatment,  while  the  results  of 
later  treatments  consist  Tor  the 
most  part  in  the  expulsion  of  the 
more  resistant  Ancylostomes. 


FINDINGS   CONCERNING   HOOKWORM 


49 


Furthermore,  it  will  be  noted  that  in  the  first  treatment  males  pre- 
dominated in  both  species,  while  in  later  treatments  females  predom- 
inated and  assumed  a  greater  proportion  to  the  males  after  each 
successive  treatment.  These  facts  show  that  the  females  are  more 
resistant  to  the  drug  than  the  males.  This  fact  is  further  substan- 
tiated in  Table  24A,  page  146,  which  also  shows  that  the  Necators  are 
more  readily  removed  than  the  Ancylostomes,  and  that  in  each 
species  the  males  are  more  easily  removed  than  the  females. 

Vulnerability  of  Worms  in  Relation  to  Dose  of  Vermicide. 

In  brief,  as  a  result  of  their  various  investigations  and  experiments, 
the  Commission  arrived  at  the  following  definite  conclusions  concern- 
ing the  relationship  between  the  amount  of  vermicide  adminis- 
tered and  the  effect  which  the  vermicide  has  on  a  given  form  of  worm: 

Lower  doses  of  vermicide,  as  compared  with  the  higher  doses,  are 
more  effective  against  the  less  resistant  forms  of  worms. 

These  lower  doses  are  relatively  ineffective,  however — as  compared 
with  the  higher  doses — against  the  more  resistant  forms. 

The  difference  between  the  effects  of  vermicide  on  the  less  resistant 
and  the  more  resistant  forms,  respectively,  becomes  less  as  the  dose 
is  increased. 

Finally,  the  larger  doses  of  vermicide  are  generally  of  particular 
use  in  getting  rid  of  the  more  resistant  forms. 

It  will  be  seen  by  reference  to  Table  25,  page  147,  that  there  is 
considerable  difference  between  the  effects  of  the  higher  and  the 
lower  doses  of  vermicide  on  different  classes  of  worms.  In  the  case 
of  the  lower  doses  the  difference  in  effect  upon  the  less  resistant 
and  the  more  resistant  forms,  respectively,  is  seen  to  be  38.6  per 
cent,  while  with  the  higher  doses  the  difference  is  21.3  per  cent. 

In  all  these  experiments,  chenopodium  was  the  vermicide  used.  A 
series  of  similar  experiments  in  which  thymol  was  employed,  also 
showed  that  in  the 
case  of  the  lower 
doses  the  differ- 
ence between  the 
effects  on  the 
more  susceptible 
and  the  more 
resistant  worm 
types,  respective- 
ly, was  large — 
42.1  percent;  with 
the  higher  doses 
the  difference  was 
inconsiderable  — 
only  4.7  per  cent. 
These  facts  are  Fig.  51. — Effect  on  Necators  and  Ancylostomes  of 
clearly  revealed  in  varying  dosages  of  thymol  and  chenopodium.  Single 
Table  26,  page  148.  trial  treatment.  (Tables  25  and  26) 


INTERNATIONAL   HEALTH    BOARD 


Relation  between  Number  of  Worms  Present  and  Facility 
with  Which  They  Are  Removed.  As  a  result  of  a  number  of 
experiments  the  Commission  was  convinced  that  it  is  easier  to  remove 
a  high  percentage  of  worms  when  there  are  many  worms  present  than 
when  there  are  few.  All  the  data  were  obtained  in  those  cases  in 
which  two  treatments  of  the  same  drug  were  given.  The  effect  of 
the  first  treatment  on  the  total  number  of  worms  may  be  compared 
with  the  effect  of  the  second  treatment  on  the  much  smaller  number  of 
worms  left  after  the  first  treatment.  The  percentage  of  worms  re- 
moved in  the  first  treatment,  when  the  number  of  worms  naturally 
is  relatively  large,  was  compared  with  the  percentage  of  worms 

removed  in  the  second  treat- 
ment, when  the  number  of 
worms  is  relatively  small.  Thus, 
when  chenopodium  was  used  (.5 
mil  three  times),  the  first  treat- 
ment removed  95.7  per  cent  of 
the  total  number  of  worms 
present.  The  second  treatment 
removed  77.6  per  cent  of  the 
total  number  of  worms  remain- 
ing after  the  first  treatment. 
In  the  case  of  all  the  drugs  and 
all  the  methods  of  treatment 
which  were  employed  and  for 
which  comparative  statistics  are 
available,  the  combined  figures 
indicate  a  similar  disparity. 
When  the  total  number  of  worms 
present  was  5,636,  the  first 
treatment  removed,  on  the  av- 
erage, 82.3  per  cent;  and  when 
the  total  number  amounted  only 
to  997,  the  percentage  removed 
by  the  second  treatment  was  only 
37.3.  It  was  therefore  perfectly 
clear  that  the  percentage  of  worms  removed  in  each  case  was  greater 
when  the  number  of  worms  was  large  than  when  it  was  small.  (See 
Table  27,  page  149.) 

Regarding  the  comparison  of  the  results  of  the  first  and  second 
treatments,  with  the  same  dose,  of  the  same  drug,  on  the  same  cases, 
certain  objections  might  be  raised.  For  example,  it  might  be  said  that 
there  may  have  been  a  difference  in  the  resistance  of  the  worms  in  the 
first  treatment;  or  that  the  high  percentage  of  worms  removed  may 
have  been  due  to  the  removal  of  the  less  resistant  worms,  while,  on 
the  other  hand,  in  the  second  treatment,  the  percentage  may  have 
been  lower  because  the  drug  was  acting  on  the  more  resistant  worms 
which  remained.  That  this  is  not  the  true  explanation  may  be  seen 


Fig.  52. — Difficulty  jof  expelling 
worms  when  number  harbored  is 
small.  (Table  27) 


FINDINGS    CONCERNING   HOOKWORM  5! 

by  noting  the  effect,  on  the  different  cases,  of  treatment  with  various 
drugs,  and  by  comparing  these  results  in  the  56  cases  in  which  the 
average  number  of  worms  per  case  was  less  than  10,  with  results  in 
the  16  cases  in  which  the  average  number  of  worms  was  more  than 
50.  It  becomes  evident  from  such  a  comparison  that  in  those  cases 
with  the  number  of  worms  over  50  (in  which  the  average  number  of 
worms  was  106)  the  percentage  of  worms  removed  (i.  e.  87.5)  was 
higher  than  the  percentage  (i.  e.  80.0)  in  cases  in  which  the  worms 
were  fewer  than  10 — an  average  of  4.5  worms  per  case. 

Work  at  District  Hospital  at  Kuala  Lumpur.  For  a  period  of 
five  consecutive  months,  the  Commission  worked  in  the  District 
Hospital  at  Kuala  Lumpur.  During  this  period  1,300  Chinese  and 
650  Tamils  were  admitted.  Post-mortem  examinations  were  made 
on  103,  or  40  per  cent,  of  the  total  number  of  fatal  cases.  These 
examinations  revealed  35  types  of  disease.  When  the  total  num- 
ber of  deaths  due  to  malaria  was  compared  with  the  total  number 
of  deaths  due  to  hookworm  disease,  it  was  found  that  there  were 
five  times  as  many  due  to  the  former  as  to  the  latter,  and  that 
there  were  2.3  times  more  deaths  from  malaria  among  the  Tamils 
than  among  the  Chinese. 

In  the  sectioning  of  the  bodies,  the  intestinal  tracts  were  care- 
fully searched  for  helminths.  Spleen  and  marrow  samples  were 
examined  for  malaria  plasmodia  or  pigment,  and  tissues  were  sec- 
tioned for  microscopic  diagnosis.  The  analyses  of  the  post-mortem 
cases  furnished  a  good  basis  for  comparing  the  incidence  of  various 
diseases  that  proved  fatal,  as  they  occurred  in  the  two  races.  The 
basis  for  comparison  was  particularly  accurate  since  the  distribu- 
tion of  the  races,  in  the  post-mortems  and  in  the  cases  admitted 
to  the  Hospital  during  the  period,  corresponded  closely  with  the 
numbers  of  the  respective  races  in  the  population  at  large  in  the 
state  of  Selangor.  Among  the  various  distinct  types  of  disease 
occurring  in  the  two  races,  dysentery,  malaria,  and  tuberculosis 
were  the  most  common;  those  due  to  external  causes  were  found 
to  be  relatively  few  in  number  (7.7  per  cent  of  the  total)  and  were 
confined  to  the  Chinese. 

Further  investigations  at  the  same  Hospital  disclosed  the  fact  that 
whereas  the  number  of  Tamils  admitted  because  of  severe  hookworm 
infection  was  disproportionately  great,  when  compared  with  the  num- 
ber of  Chinese,  there  were  no  deaths  certainly  traceable  to  hookworm 
infection  among  them,  while  among  the  Chinese  there  were  four 
deaths  attributable  to  that  cause.  In  other  words,  while  there  were 
66  Chinese  to  34  Tamils  constantly  present  in  the  hospital  throughout 
the  year,  there  were  among  the  cases  of  severe  anemia  admitted  to 
the  Commission's  ward,  6  Tamils  having  over  500  worms,  with  no 
deaths,  and  5  Chinese  having  over  500  worms,  with  a  record  of  4 
deaths  out  of  5.  It  would  appear  from  these  facts  that  while  Tamils 
may  harbor  many  worms  and  may  suffer  severe  anemia,  there  is  no 
record  of  mortality.  While  the  Tamils  examined  were  found  to 


INTERNATIONAL   HEALTH    BOARD 


harbor  almost  as  many  hookworms  as  the  Chinese  and  while  their 
hemoglobin  was  nearly  as  low,  none  of  them  died. 

This  difference  in  the  severity  of  the  disease  as  between  the  two 
races  may  possibly  have  been  due  to  the  fact  that  the  mouth  parts  of 
the  A ncylostoma  duodenale,  a  species  of  which  the  Chinese  had  the 
larger  proportion,  are  larger  than  the  mouth  parts  of  the  Necator. 
This  anatomical  difference  would  enable  the  former  to  inflict  more 
serious  wounds  in  the  mucosa,  thus  causing  a  greater  degree  of  anemia. 
(For  certain  clinical  studies  see  Chapter  VII,  page  65.) 

Work  at  Singapore.  At  the  quarantine  camp  on  St.  John's 
Island,  Singapore,  research  and  investigation  work  was  undertaken 

for  much  the  same  purpose  as 
that  which  actuated  operations 
at  Port  Swettenham,  except  that 
the  coolies  were  Chinese  instead 
of  Tamils.  Indians  examined 
at  Port  Swettenham  came,  for 
the  most  part,  from  the  south- 
ern districts  of  India.  Most 
of  the  Chinese  examined  at  Sin- 
gapore came  from  the  southern 
provinces  of  China.  A  consid- 
erable percentage  of  the  Chinese 
who  entered  the  Malay  Penin- 
sula at  Singapore  had  a  history 
of  previous  residence  other  than 
China — usually  the  Malay  Pen- 
insula. Of  the  304  whose  feces 
were  examined  microscopically 
but  who  were  not  treated,  203, 
or  66.8  per  cent,  were  found 
positive  for  hookworm  ova.  Of 


NO  FORMER  RESIDENCE  OTHER  THAN  CHINA 
FORMER  RESIDENCE  OTHER  THAN  CHINA 


Fig.  53. — Average  hemoglobin 
and  average  number  of  hookworms 
harbored  by  eighty-eight  Chinese 
treated  at  Singapore.  (Table  28) 


these  Chinese  immigrants,  88 
were  treated  for  hookworm  in- 
fection. Of  the  88,  as  many 
as  60  had  no  previous  residence 
other  than  China,  and  the  former 


residence  of  most  of  the  remaining  28  was  the  Malay  Peninsula. 
The  newcomers  also  proved  to  harbor  a  larger  average  number 
of  hookworms  than  those  who  had  been  longer  in  the  Malay  Penin- 
sula. That  is,  there  were  31.5  worms  per  individual  among  the 
60  persons  who  had  resided  previously  only  in  China,  as  against 
the  20  worms  per  person  among  the  28  who  had  had  a  former  resi- 
dence other  than  China.  The  average  hemoglobin  in  both  groups 
was  found  to  be  practically  the  same.  Of  the  88  who  were  treated,  62 
were  men,  20  were  women,  and  6  were  children.  The  percentage  of 
hookworm  infection  among  the  men  was  90.3,  among  the  women  85, 
and  among  the  children  83.3.  The  gross  percentage  of  hookworm 


FINDINGS   CONCERNING   HOOKWORM  53 

infection  among  men,  women,  and  children  was  88.6.  The  average 
hemoglobin  percentage  among  the  men  was  77.5,  among  the  women 
65.5,  and  among  the  children  79.5.  As  to  both  hookworm  infection 
and  average  hemoglobin,  practically  the  same  percentages  were  found 
among  the  immigrants  who  were  treated  at  Singapore  as  among  those 
who  were  later  treated  in  the  Federated  Malay  States.  (See  Table 
28,  page  150.) 

Work  in  the  Fiji  Islands.  Hookworm  infection,  it  was  found, 
prevailed  in  the  island  of  Viti  Levu  (Fiji)  to  as  great  an  extent  as  in 
the  Federated  Malay  States  and  in  Java.  In  fact,  in  the  adult  male 
Indian  and  Fijian  populations  the  incidence  was  found  to  be  100 
per  cent.  There  is  no  doubt  that  hookworms  were  brought  into  the 
country  by  Indian  immigrants;  but  severe  infections  were  also  en- 
countered among  the  aboriginal  inhabitants  of  the  island.  In  all, 
190  cases  were  examined,  including  Indians,  Fijian  half-castes,  and 
Europeans;  these  cases  included  both  adult  males  and  females,  and 
children.  Of  this  total  number,  183,  or  96.3  per  cent,  were  found  to 
be  infected.  Half-castes  and  European  children  were  found  to  harbor 
very  few  worms,  although  they  run  barefooted  throughout  the  year 
and  are  thus  exposed  to  infection.  European  adults  were  found  to  be 
free  from  hookworm  ova — except  those  who  were  born  in  Fiji;  these, 
in  all  likelihood,  had  acquired  infection  during  youth  or  adolescence 
while  going  barefooted.  (See  Table  29,  page  151.) 

Among  the  indentured  coolies  who  underwent  medical  inspection 
and  hookworm  treatment  as  well,  whenever  clinical  evidence  of 
anemia  existed  there  was  some  mild  anemia.  Only  two  cases  of 
severe  anemia  were  detected. 

The  free  coolies  who  live  out  in  the  flat,  wet  cane-fields  were  all 
heavily  infected.  On  their  premises  the  ground  water  was  high  and 
the  shallow  latrines  in  use  were  by  no  means  sanitary.  Among  this 
class  there  were  cases  of  anemia  of  all  grades,  from  severe  to  mild,  and 
their  condition,  as  exhibited  at  the  time  of  muster  and  as  recorded  by 
the  hemoglobinometer,  was  distinctly  below  that  of  the  indentured 
men.  These  free  coolies  are  not  obliged  to  submit  to  medical  inspec- 
tion, and  do  not  receive  free  hospital  treatment.  Consequently  they 
had  received  no  hookworm  treatment  since  the  expiration  of  their 
period  of  indenture,  from  five  to  twenty  years  before.  They  were 
found  to  be  very  approachable,  and  no  difficulty  was  experienced  in 
persuading  them  to  enter  the  Hospital  for  thorough  treatment. 

The  hookworm  campaign  now  being  conducted  by  the  Fiji  Medi- 
cal Department,  with  the  co-operation  of  the  International  Health 
Board,  reaches  a  similar  class  of  free  coolies,  and  should  result  in 
considerable  improvement  in  their  physical  condition.  These  people 
are  for  the  most  part  thrifty  farmers  on  a  small  scale.  Since  they 
are  disposed  to  be  exceedingly  frugal  in  eating,  it  is  quite  probable 
that  the  anemia  caused  by  hookworm  infection  is  intensified  in  this 
class  by  chronic  conditions  of  innutrition. 


54 


INTERNATIONAL   HEALTH    BOARD 


FINDINGS   CONCERNING   HOOKWORM  55 

The  native  population  represented  by  Fijians  living  in  remote  dis- 
tricts, out  of  contact  with  Indian  sources  of  hookworm  infection,  was 
found  to  harbor  Necator  americanus  and  Ancylostoma  ceylanicum  (the 
latter  being  derived  from  the  dogs).  Ancylostoma  duodenale  was 
entirely  absent.  This  leads  to  the  conviction  that  Necator  americanus 
is  a  natural  parasite  of  the  Fijians,  and  that  very  likely  Polynesians 
as  well  as  Melanesians  will  be  found  to  harbor  this  species  exclusively, 
except  in  places  where  the  people  may  be  living  in  contact  with 
Asiatics  who  harbor  Ancylostoma  duodenale. 


HOOKWORM-SPECIES  FORMULA  ACCORDING  TO  RACE 


The  species  was  always  very  carefully  determined  in  the  case  of 
all  the  hookworms  that  were  recovered  in  the  course  of  treatment, 
and  a  careful  tabulation  made  of  the  distribution  of  species  in  rep- 
resentatives of  the  various  races  and  of  the  effect  of  occupation  and 
environment  in  such  distribution.  As  a  result  it  was  found  that 
the  proportion  of  Ancylostomes  to  Necators  varied  considerably  in 
the  different  races.  (See  Table  30,  pages  152  and  153.)  Evidence  was 
also  found  that  both  occupation  and  environment  tend  to  limit  or 
to  influence  the  proportion  of  the  species  of  hookworms  with  which 
certain  individuals  are  infected.  The  distribution  and  relative  num- 
bers of  Ancylostoma  duodenale  are  important  on  account  of  their 
relation  to  effective  and  economical  treatment.  For,  since  there  is 
a  definite  relation  between  dosage  of  drug  and  respective  species  of 
worm  (more  drug  being  required  to  dislodge  the  more  resistant  Ancy- 
lostoma duodenale),  it  is  highly  desirable  to  know  the  Ancylostome 
formula  of  the  people  who  are  being  treated.  If  this  is  known  it  is 
comparatively  simple  to  adjust  the  dosage  of  the  drug  efficiently  and 
economically,  according  to  the  species  of  worms  which  are  to  be 
removed.  It  has  been  found  convenient  to  express  the  hookworm- 
species  formula  in  terms  of  percentage  of  Ancylostomes,  because, 
this  being  the  more  difficult  worm  to  remove  by  anthelrnintics,  such 
terms  indicate  in  the  best  manner  the  degree  of  necessity  of  using 
larger  dosages  of  the  vermicide. 

Malays.  At  Kampong  Bharu,  38  kampong  boys  were  treated. 
These  were  found  to  harbor  a  total  of  2,262  hookworms,  of  which 
number  2,257  were  Necator  americanus,  and  5  were  Ancylostomes.  Of 
these  5  Ancylostomes,  2  were  ,4.  ceylanicum  and  3  were /I.  duodenale. 
It  will  thus  be  seen  that  the  percentage  of  Ancylostomes  among  these 
boys  was  only  0.22.  The  boys  of  this  kampong,  so  far  as  their  cus- 
toms indicate,  probably  re-infect  one  another,  for  they  are  not  to 
any  extent  subject  to  infection  by  Chinese,  Tamils,  or  others,  in- 
asmuch as  they  live  within  their  own  kampongs. 

The  Malay  kampong  at  Ulu  Gombak  yielded  very  much  the  same 
results.  At  the  kampong  39  boys  were  treated,  and  from  them  a 


56  INTERNATIONAL   HEALTH   BOARD 

total  of  1,559  hookworms  were  recovered,  of  which  number  1,546 
were  Necator  americanus  and  13  were  Ancylostomes.  Of  these  13 
Ancylostomes,  6  were  A.  ceylanicum  and  7  were  A.  duodenale.  It 
will  thus  be  seen  that  the  percentage  of  Ancylostomes  among  these 
boys  was  0.8.  It  is  also  noteworthy  that  nearly  one-half  the 
the  Ancylostomes  harbored  were  A.  ceylanicum;  this  species,  while 
comprising  about  60  per  cent  of  the  hookworms  found  in  the  dogs  of 
Kuala  Lumpur,  was  only  rarely  found  in  adult  Chinese  or  Tamils. 

The  adult  Malays  were  easily  classed  in  three  distinct  groups.  In 
the  first  group,  consisting  of  Malays  principally  in  the  Malay  Penin- 
sula, there  were  16  persons  with  a  total  of  1,138  hookworms,  of 
which  number  1,128  were  Necator  americanus  and  10  were  A.  duo- 
denale. The  percentage  of  Ancylostomes  in  the  first  group  was 
therefore  0.9  In  the  second  group,  consisting  of  Malays  principally 
from  Java,  there  were  12  persons  with  a  total  of  1,757  worms,  of  which 
number  1,711  were  Necator  americanus  and  46  were  A.  duodenale. 
The  percentage  of  Ancylostomes  in  this  second  group  was  therefore 
2.6.  In  the  third  group,  consisting  of  Malays  principally  from 
Sumatra,  there  were  28  persons,  with  a  total  of  2,746  hookworms, 
of  which  number  58  were  Ancylostomes,  including  7  that  were  A. 
ceylanicum.  The  percentage  of  Ancylostomes  in  this  third  group 
was  therefore  2.1. 

Chinese.  The  Chinese  were  found  to  fall  into  two  groups.  The 
persons  in  the  first  group  consisted  principally  of  those  who  came  to 
the  Federated  Malay  States,  usually  as  adults,  from  the  southern 
provinces  of  China.  To  a  considerable  extent  their  worm-species 
formula  must  therefore  represent  the  infection  received  in  China. 
Even  after  these  people  had  spent  a  number  of  years  in  the  Federated 
Malay  States,  their  habits  and  their  superior  numbers  would,  as  a 
rule,  lead  to  their  acquiring  re-infection  from  one  another  rather 
than  from  other  races.  It  may  be  assumed  that  the  worm-species 
of  the  sinkehs,  or  newcomers  from  China,  would  give  the  proportion 
of  the  species  as  it  exists  in  the  people  from  the  southern  provinces  of 
China.  Forty-six  sinkehs  were  treated  at  the  quarantine  camp  at 
St.  John's  Island,  Singapore.  From  them  1,241  worms  were  obtained, 
of  which  number  420  were  A.  duodenale  and  821  were  Ar.  america- 
nus. Thus  the  gross  percentage  of  Ancylostomes  was  33.8.  There 
were  10  cases  of  purely  Necator  infections  in  this  group,  which 
harbored  a  total  of  148  worms.  Of  the  whole  group,  36.9  per  cent 
fell  within  the  formula. 

Among  the  cases  treated  at  the  District  Hospital  at  Kuala  Lumpur 
there  were  79  Chinese,  who  yielded  5,191  hookworms,  of  which 
number  1,994  were  A.  duodenale  and  3,197  were  Necator  americanus. 
The  percentage  of  Ancylostomes  in  this  group  was  38.4.  It  is  inter- 
esting to  observe  that  there  were  12  cases  in  this  group  with  infec- 
tions from  Necator  americanus,  and  37  other  cases  whose  percentage 
of  Ancylostomes  was  below  the  apparent  average  for  the  whole  group. 
The  men  of  this  group  had  lived  in  the  Federated  Malay  States  for 


FINDINGS   CONCERNING   HOOKWORM  57 

varying  periods  up  to  twenty  years.  It  is  entirely  possible  that  they 
represented  to  some  extent  examples  of  infections  acquired  from  other 
races.  The  soil  and  climate  of  the  Federated  Malay  States  did  not 
seem  inimical  to  the  larvae  of  A.  duodenale,  for  the  group  consisted 
of  33  examples  of  men  who  were  infected  with  this  species,  and  who 
had  lived  in  the  country  from  10  to  20  years.  Therefore,  they  had 
undoubtedly  acquired  the  infection  during  the  term  of  their  residence. 

Straits-born  Chinese.  Only  two  cases  of  Straits-born  Chinese 
were  treated.  Nevertheless,  the  results  found  were  significant,  for 
the  species  formula  is  that  of  the  natives  of  the  country,  and  not 
that  of  the  Chinese.  These  two  men  were  hospital  dressers,  born 
in  Malacca.  One  of  the  two  cases  represents  the  first  generation, 
the  other  the  second  generation,  born  in  the  country.  On  treatment, 
one  yielded  42  Necators  and  the  other  yielded  30  Necators.  Ancylos- 
tomes  were  not  obtained  from  either.  The  percentage  of  Ancylos- 
tomes,  therefore,  in  these  two  Straits-born  Chinese  was  nil. 

Tamils  and  South  Indians.  The  natives  of  South  India — 
Tamils,  Telegus,  and  Malabaris — have  a  worm-species  formula 
approaching  very  closely  that  of  the  Malays  of  the  Federated  Malay 
States. 

During  the  time  that  treatments  were  being  carried  out  at  the  Port 
Swettenham  quarantine  camp,  10,455  hookworms  were  recovered, 
of  which  number  312  were  A.  duodenale  and  10,143  (the  remainder) 
were  N.  americanus.  The  percentage  of  Ancylostomes,  therefore, 
was  2.9  among  Tamils  entering  the  country.  A  number  of  these 
10,455  worms  were  obtained  from  three  treatment  squads.  In  these 
treatments,  4,363  worms  were  obtained,  of  which  number  89  were  .4. 
duodenale  and  4,274  (the  remainder)  were  N.  americanus.  The 
percentage  of  Ancylostomes,  therefore,  in  this  sub-group,  was  2.0. 
This  percentage  probably  represents  the  proportion  of  the  two 
species  of  hookworms  among  the  natives  of  southern  India. 

During  the  early  part  of  1916,  a  number  of  Malabaris  from  South 
India  who  had  lived  in  the  Federated  Malay  States  but  a  few  months, 
were  treated.  Altogether  there  were  25  cases,  yielding  3,491  worms, 
of  which  number  30  were  A.  duodenale  and  3,461  (the  remainder)  N. 
americanus.  The  percentage  of  Ancylostomes,  therefore,  among 
these  Malabaris  was  0.86. 

The  treated  cases  at  the  District  Hospital  included  118  Tamils 
who  had  resided  in  the  Federated  Malay  States  for  varying  periods 
up  to  twenty  years.  From  these  Tamils,  12,806  worms  were  obtained, 
of  which  number  658  were  A.  duodenale  and  12,148  (the  remainder) 
N.  americanus.  The  percentage  of  Ancylostomes,  therefore,  was 
5.1.  This  percentage  probably  represents  the  modicum  of  infection 
suffered  by  Tamil  residents  in  the  Federated  Malay  States,  where 
there  is  a  large  but  scattered  Chinese  population  with  its  high 
Ancylostome  index. 

The  comparison  of  the  species  percentage  composition  of  newly 
arrived  Tamils,  or  Malabaris,  with  those  Tamils  who  transported 


58       INTERNATIONAL  HEALTH  BOARD 

and  buried  night  soil  obtained  from  the  city  of  Kuala  Lumpur 
(which  has  a  large  Chinese  population),  furnishes  further  evidence 
of  the  infection  of  Tamils  from  Chinese  sources.  Fifty-seven  night- 
soil  coolies  (men,  women,  and  children)  were  treated.  These  coolies 
had  followed  their  vocation  for  periods  varying  up  to  eleven  years. 
The  total  number  of  worms  harbored  by  this  group  of  57  persons 
was  7,259,  of  which  number  806  were  A.  duodenale  and  6,453  (the 
remainder)  were  N.  americanus.  The  percentage  of  Ancylostomes, 
therefore,  in  this  group  of  coolies,  was  11.1. 

Undoubtedly  this  percentage  represents  the  infection  derived  from 
Chinese  sources  by  the  handling  of  night  soil.  This  group  of  coolies 
was  compared  with  the  group  of  Tamil  coolies  engaged  in  road- 
repairing.  Those  in  the  latter  group  were  not  exposed  to  hook- 
worm infection  in  the  same  degree  as  were  the  night-soil  coolies. 
A  group  of  35  road  coolies  were  treated.  This  group  was  made  up 
of  men,  women,  and  youths.  None  in  the  group  had  ever  worked 
as  a  night-soil  coolie.  They  had  all  lived  in  the  Federated  Malay 
States  for  periods  varying  up  to  fifteen  years,  sometimes  employed  on 
estates  and  sometimes  on  public  works.  As  the  result  of  treatment 
they  yielded  2,870  worms,  of  which  number  59  were  A.  duodenale 
and  2,811  (the  remainder)  N.  americanus.  In  this  coolie  group, 
whose  members  were  not  especially  exposed  to  infection  from 
Chinese  sources,  and  in  whom  the  South  Indian  formula  was  retained, 
the  percentage  of  Ancylostomes  was  2.0.  . 

People  of  Northern  India.  It  appears  that  the  people  of  north- 
ern India  have  a  species  percentage  composition  differing  from  that 
of  the  people  of  southern  India.  There  are  relatively  few  people 
from  northern  India  in  the  Federated  Malay  States,  but  the  people 
of  that  region  are  represented  in  the  Commission's  series  of  Sikhs 
and  Mohammedan  police  from  the  Punjab.  These  men,  however, 
had  lived  in  the  Federated  Malay  States  for  several  years  and  the 
Ancylostome  index  natural  to  them  in  their  own  country  cannot  be 
positively  ascertained.  Thirteen  Sikhs  were  treated  in  Hospital 
No.  2.  All  who  had  lived  in  the  Federated  Malay  States  for  periods 
of  10  years  or  over,  or  who  had  worked  on  estates,  were  excluded. 
It  was  found  that  the  7  remaining  men  harbored  only  41  hookworms, 
of  which  number  21  were  A.  duodenale  and  20  (the  remainder)  N. 
americanus.  The  percentage  of  Ancylostomes,  therefore,  in  this 
group  was  51.2. 

On  the  other  hand,  if  we  take  those  who  had  lived  for  periods  of 
10  years  or  more  in  the  Federated  Malay  States,  or  who  had  been 
employed  on  estates  (where  there  would  be  more  opportunity  for 
acquiring  infection  by  Necators),  we  have  3  cases  harboring  a  total 
of  39  worms,  of  which  number  5  were  A.  duodenale  and  34  (the  re- 
mainder) N.  americanus.  The  percentage  of  Ancylostomes,  there- 
fore, in  this  group,  was  12.5.  In  Hospital  No.  1,  8  Sikhs  were 
treated.  These  may  be  separated  into  2  groups,  the  first  consist- 
ing of  those  who  had  lived  in  the  Federated  Malay  States  10  years 


FINDINGS   CONCERNING  HOOKWORM  59 

or  more,  and  the  second  group  consisting  of  those  who  had  lived  in 
the  Federated  Malay  States  less  than  that  time.  Investigation  re- 
vealed the  fact  that  in  the  first  group  there  were  6  cases,  harboring 
a  total  of  83  worms,  of  which  number  65  were  A.  duodenale  and  18 
(the  remainder)  N.  americanus.  The  percentage  of  Ancylostomes, 
therefore,  in  this  group  was  78.3.  In  the  second  group  2  cases  were 
found  harboring  a  total  of  139  worms,  of  which  number  6  were  A. 
duodenale  and  133  (the  remainder)  N.  americanus.  The  percentage 
of  Ancylostomes,  therefore,  in  this  group  was  4.3. 

The  conclusion  which  may  be  drawn  from  these  figures  is  that  the 
Ancylostome  index  of  the  people  of  northern  India,  at  about  30 
degrees  N.  latitude,  would  be  found  to  be  as  high  as  that  of  the 
people  in  southern  China,  living  at  23  degrees  N.  latitude. 

Japanese.  A  group  of  four  Japanese  prostitutes  who  had  been 
in  the  Federated  Malay  States  three  years  or  less,  were  treated. 
These  4  women  were  found  to  harbor  61  worms,  of  which  number  19 
were  A.  duodenale  and  42  (the  remainder)  N.  americanus.  The 
percentage  of  Ancylostomes,  therefore,  in  this  group  was  31.1.  The 
indications  are  that  the  Japanese  have,  in  common  with  the  races 
farther  north,  a  higher  Ancylostome  index  than  the  natives  of  the 
Federated  Malay  States. 

Europeans.  Only  three  of  the  six  Europeans  (all  planters)  from 
whom  hookworms  were  obtained  upon  treatment,  had  certainly 
acquired  their  infection  in  the  Federated  Malay  States.  The  other 
three  may  have  acquired  it  there,  but  inasmuch  as  they  had  lived  in 
other  tropical  countries  before  coming  to  that  country,  it  is  perfectly 
possible  that  they  may  have  acquired  their  infection  elsewhere.  Of 
the  3  men  who  had  never  lived  in  places  other  than  the  Federated 
Malay  States  where  hookworm  infection  was  known  to  occur,  one 
harbored  8  worms,  all  of  which  were  A.  duodenale;  another  harbored 
9  worms,  2  of  which  were  A.  duodenale;  and  the  third  man  harbored 
20  worms,  1  of  which  was  A.  duodenale.  It  is  highly  probable  that 
the  planters  who  become  infected  in  the  Federated  Malay  States 
derive  their  infection  from  mixed  sources. 

While  it  is  comparatively  easy  to  determine  whether  or  not  a 
group  of  Tamils  have  become  infected  from  Chinese  sources,  it 
is  extremely  difficult  to  say  whether  Chinese  old  residents  are 
being  infected  by  Tamils  or  Malays.  Recently  arrived  Tamils  and 
Malays  rarely  harbored  A.  duodenale,  or  else  harbored  these  worms 
in  very  small  numbers.  On  the  other  hand,  it  is  known  that  the 
Chinese  harbored  considerable  numbers  of  N.  americanus.  Further- 
more, about  15  per  cent  of  the  sinkehs,  or  newcomers,  examined 
at  St.  John's  Island,  showed  infection  according  to  the  Tamil  or 
Malay  formula;  that  is  to  say,  among  other  worms  a  very  large 
majority  of  Necators  was  found.  There  is,  however,  always  some 
room  for  doubt  in  the  case  of  a  Chinese  declaring  himself  a  sinkeh; 
he  may  be  a  former  resident  who  is  disinclined  to  admit  the  fact. 


6O  INTERNATIONAL    HEALTH    BOARD 

Javanese.  In  Java  there  were  geographical  and  racial  differences 
in  the  proportion  of  the  species  of  worms  present.  For  example, 
in  the  kampongs  of  Batavia  a  total  of  2,935  hookworms  was  obtained, 
of  which  number  26  were  found  to  be  A.  duodenale  and  2,909  (the 
remainder)  N.  americanus.  In  this  group,  the  percentage  of  Ancy- 
lostomes  was,  therefore,  0.8.  The  same  difference  was  found  in 
Preanger.  At  Endil,  25  natives  were  treated  and  from  them  1,275 
worms  were  obtained,  only  2  of  which  were  Ancylostomes;  both  of 
these  were  A.  ceylanicum.  In  West  Java,  in  the  three  places  visited, 
the  proportion  of  Ancylostomes  was  found  to  be  very  small  indeed. 
The  worm  formula,  in  fact,  resembled  that  of  the  South  Indians, 
the.  Sumatrans,  or  the  natives  of  the  Federated  Malay  States. 

In  Mid-Java,  the  Ancylostomes  appeared  in  larger  numbers  in 
every  kampong  and  were  evenly  distributed  throughout  the  popula- 
tion. At  Gebongelir,  Mid-Java,  50  natives  were  treated  and  from 
them  2,339  worms  were  obtained,  of  which  308  were  A.  duodenale  and 
2,031  (the  remainder)  N.  americanus.  The  percentage  of  Ancylos- 
tomes in  this  group  was,  therefore,  13.1.  At  Kalimaro,  which  is 
one  and  one-half  miles  away,  24  persons  upon  treatment  yielded 
5,140  worms,  322  of  which  were  A.  duodenale  and  4,818  (the  remain- 
der) N.  americanus.  The  percentage  of  Ancylostomes  was,  there- 
fore, 6.2.  At  Kebasekan,  the  25  persons  who  were  treated  yielded 
a  total  of  4,082  worms,  of  which  219  were  A.  duodenale  and  3,863 
(the  remainder)  N.  americanus.  Therefore,  in  this  kampong,  the 
percentage  of  Ancylostomes  was  5.4.  At  Krakal-Karangsari,  28 
natives  were  treated  and  from  them  10,861  worms  were  obtained. 
Of  this  number,  770  were  A.  duodenale  and  10,091  (the  remainder) 
N.  americanus.  The  percentage  of  Ancylostomes  was,  therefore,  7.0. 

Thus,  a  well-marked  difference  was  noted  between  the  Ancylos- 
tome  index  of  the  Malays  of  Batavia  and  the  Sudanese  of  Preanger 
on  the  one  hand,  with  their  universally  low  index,  and  the  Javanese 
of  Mid-Java  on  the  other  hand,  with  their  uniformly  higher  index. 
The  prisoners  at  the  Batavia  jail  were  treated  and  examined  for 
evidences  -along  these  lines.  These  prisoners,  in  spite  of  the  fact 
that  there  seemed  to  be  no  possibility  of  acquiring  new  hookworm 
infections  in  the  jail,  showed  an  Ancylostome  percentage  of  9.2  (with 
a  total  worm  count  of  8,683),  while  the  people  in  the  neighboring 
kampong — even  within  a  stone's  throw  of  the  jail — had  a  low  Ancy- 
lostome index.  It  would  appear  from  this  that  their  infection  must 
have  been  acquired  elsewhere,  and,  as  a  matter  of  fact,  this  theory 
was  confirmed  by  separating  the  men  into  groups  according  to  the 
particular  part  of  the  Netherlands  Indies  from  which  they  came. 

For  example,  there  were  9 prisoners  who  gave  their  place  of  residence 
as  Mid-Java  or  East  Java,  whose  total  worm  count  was  755,  of 
which  57  were  A.  duodenale.  In  other  words,  they  showed  an 
Ancylostome  percentage  of  7.5.  On  the  other  hand,  2  persons  who 
gave  their  place  of  residence  as  Batavia  or  Preanger  showed  an 
Ancylostome  percentage  of  only  0.76,  for  out  of  a  total  of  130  worms 
yielded  by  these  2  persons,  only  one  was  A.  duodenale. 


Fig.  55. — Two  cases  of  hookworm  anemia  in  Mid-Java. 
The  younger  man  was  an  imbecile  and  total  worm  count 
was  not  obtained.  The  other  case  harbored  843  hook- 
worms. Spleen  and  plasmodia,  negative;  hemoglobins 
were  13%  and  10%  respectively 


Fig.  56 — Cases  of  hookworm  anemia  and  malarial  anemia 
contrasted.  The  Tamil  harbored  1,063  hookworms;  hem- 
oglobin was  5-10%  and  spleen  was  negative.  The  Chinese 
harbored  only  82  hookworms;  hemoglobin  was  30%  and 
spleen  was  enlarged  a  hand's  breadth 


FINDINGS   CONCERNING   HOOKWORM  63 

Sumatrans.  Regarding  the  worm  formulae  of  the  prisoners 
coming  from  Sumatra  and  from  the  other  islands  in  the  Netherlands 
Indies,  an  equally  well-marked  difference  was  noted  between  the 
formula  of  the  Malays  from  Sumatra,  for  example,  and  the  formula 
of  the  natives  of  the  islands  of  Madura,  Bali,  Lombok,  and  Timor. 
Madura  is  a  small  island  almost  touching  the  eastern  end  of  Java. 
The  inhabitants  have  colonized  in  East  Java  and  are  becoming 
assimilated.  There  were  16  prisoners  from  Madura,  from  whom 
1,263  worms  were  obtained,  of  which  173  were  A.  duodenale;  thus 
the  Ancylostome  percentage  was  13.7. 

The  Ancylostome  index  of  the  natives  found  on  the  islands  of 
Bali,  Lombok,  and  Timor  resembles  that  of  the  people  of  Mid-Java 
and  East  Java  more  closely  than  it  does  that  of  the  people  of  West 
Java.  Bali,  with  S  cases  having  a  total  worm  count  of  348,  gave  an 
Ancylostome  percentage  of  4.0.  Lombok,  with  4  cases  having  a 
total  worm  count  of  479,  gave  an  Ancylostome  index  of  3.3;  Timor, 
with  4  cases  having  a  total  worm  count  of  100,  gave  an  Ancylostome 
index  of  62.0  per  cent. 

Among  those  examined  there  were  from  Sumatra  12  cases,  which 
fell  into  the  group  corresponding  to  West  Java  and  Malaya.  The 
total  worm  count  of  these  12  cases  was  919,  and  of  that  total  only 
7  worms  were  A.  duodenale;  the  Ancylostome  percentage  was  there- 
fore 0.9.  There  were  two  cases  from  Sumatra,  with  formulae 
resembling  those  of  the  Chinese.  One  of  these  two  men  was 
questioned  at  the  time  of  examination,  and  was  found  to  be  a  Madras 
Tamil  employed  as  a  cart-driver  on  a  tobacco  estate,  where  he  lived 
for  five  years  close  to  the  Chinese  lines.  These  2  cases  yielded  38 
worms,  of  which  25  were  A.  duodenale;  hence  the  percentage  of 
Ancylostomes  was  65.0.  These  data,  of  course,  would  seem  to  point 
to  the  fact  that  the  men  were  infected  from  Chinese  sources. 

From  Celebes  there  were  4  persons  with  a  total  worm  count  of 
523;  all  of  the  worms  were  Necators.  This  means,  of  course,  that 
the  Ancylostome  index  was  nil.  The  island  of  Celebes  lies  to  the 
north,  and  is  not  a  part  of  the  chain  of  which  Mid-Java,  Madura, 
Bali,  Lombok,  and  Timor  are  all  units. 

The  Chinese  treated  in  the  jail  were  of  three  groups.  In  the 
first  group — Chinese  who  were  born  in  China  but  who  had  lived 
in  Sumatra,  where  there  was  a  low  Ancylostome  index — there  were 
13  cases  with  838  worms,  of  which  255  were  A.  duodenale.  The 
percentage  of  Ancylostomes,  therefore,  in  this  group  was  30.4,  which 
is  a  Chinese  formula.  In  the  second  group — Chinese  who  were  born 
in  Mid-Java — there  was  only  one  case,  with  a  total  count  of  57 
worms,  of  which  11  were  A.  duodenale.  The  percentage  of  Ancylos- 
tomes in  this  group  was,  therefore,  19.3,  which  is  a  Mid-Java  formula. 
In  the  third  group — Chinese  who  were  born  in  West  Java — there 
was  also  but  one  case,  whose  worm  count  was  123,  and  only  one 
worm  was  A.  duodenale.  The  percentage  of  Ancylostomes  was, 
therefore,  only  0.8,  which  is  a  West  Java  formula. 


64        INTERNATIONAL  HEALTH  BOARD 

It  does  not  seem  likely  that  the  presence  of  A.  duodenale  in  Mid- 
Java  or  East  Java  and  in  the  eastern  chain  of  islands,  is  at  all  due 
to  the  presence  of  Chinese,  for  the  native  stock  greatly  outnumbers 
them;  moreover,  the  Java-born  Chinese  appear  to  evidence  the 
formula  of  the  natives  of  the  locality,  rather  than  the  formula  of  the 
Chinese  born  in  China. 

It  is  quite  possible  that  the  Ancylostome  index  affords  a  clue  to 
the  ethnic  origin  or  composition  of  the  natives  of  Malaya,  Java,  and 
the  other  islands  of  the  Netherlands  Indies,  and  that  a  high  Ancylos- 
tome formula  indicates  a  large  admixture  of  ethnic  stocks  from 
northern  India  or  elsewhere.  It  will  be  remembered  that  centuries 
ago  a  considerable  Hindu  civilization  flourished  in  Mid-Java,  East 
Java,  and  Bali.  Many  of  the  Malays  of  the  Federated  Malay 
States  claim  Sumatra  as  their  ancient  home — indeed,  it  is  often 
stated  that  it  is  the  ancient  home  of  the  race — and  the  Ancylostome 
formulae  of  the  natives  of  the  two  countries  appear  to  be  identical. 
(See  Table  30,  page  152.) 


CHAPTER  VII 


FINDINGS   CONCERNING  MALARIA 

Post-mortem  Data.  At  the  District  Hospital  at  Kuala  Lumpur 
a  number  of  post-mortem  examinations  were  made.  It  was  found 
that  the  deaths  due  to  malaria  could  be  classified  in  two  groups. 

The  first  group  was  made  up  of  those  who  suffered  from  acute 
pernicious  malaria,  in  which  cases  myriads  of  plasmodia  were  found  in 
the  spleen,  bone-marrow,  or  brain.  There  were  4  such  cases,  3  of 
them  Tamils  and  1  a  Chinese.  This  proportion  corresponds  with  the 
distribution  of  these  races  on  estates,  and  appears  to  represent  the 
degree  of  exposure  to  infection  from  malaria  to  which  they  were 
subjected. 

The  second  group  consisted  of  those  who  suffered  from  chronic 
cachexia  as  the  result  of  neglected,  untreated  malaria.  While  the 
individual  cases  of  this  group  were  not  overwhelmed  by  large  num- 
bers of  plasmodia,  their  blood-forming  organs  were  gradually  over- 
powered by  small,  but  repeated  dosages  of  the  poison.  Physical 
debility,  incapacity  for  work,  dysentery,  malnutrition,  and  semi- 
starvation  all  contributed  to 
hasten  the  development  of  a 
cachexia,  and  thus  to  bring 
about  the  coolie's  death. 

Inasmuch  as  cachexia  occurs 
irrespective  of  the  presence  or 
absence  of  hookworms,  it  is 
probably  safe  to  assume  that 
these  cases  of  the  disease  were 
due  to  malaria.  Eleven  cases 
of  anemia  were  found  to  fall  in 
this  group.  The  number  of 
worms  recovered  was  not  suffi- 
cient to  cause  any  measurable 
degree  of  anemia,  and  it  may 
therefore  be  assumed  that  the 
cause  of  death  was  long-contin- 
ued exposure  to  malaria.  From 
these  post-mortem  examina- 
tions, it  would  appear  that 
hookworm  disease  was  not  a 
cause  of  death  among  the  Tamils 
in  the  series  &•  — Results  of  fecal  examina- 

tions   for    hookworm    disease    and 

Blood  and  Feces  Examin-  blood  examinations  for  malaria. 
ations.  Blood  examinations  District  Hospital  at  Kuala  Lumpur, 
were  made  on  588  patients  at  By  race.  (Table  31) 

65 


FECES  POSITIVE  TO  HOOKWORM  OVA 
BLOOD  POSITIVE  TO  MALARIA  PLASMODI* 


66 


INTERNATIONAL   HEALTH    BOARD 


the  District  Hospital  at  Kuala 
Lumpur,  and  35.4  per  cent  were 
found  positive  for  malaria  para- 
sites. Feces  examinations  were 
made  on  524  patients  and  76.2 
per  cent  were  found  positive  for 
hookworm  ova.  If  the  first  stool 
specimen  was  found  negative,  a 
second  specimen  was  obtained  in 
a  few  days  for  another  examina- 
tion. Both  blood  and  feces  ex- 
aminations were  made  for  522  of 
the  total  588,  including  Chinese, 
Tamils,  and  Bengalese:  35.2  per 
cent  proved  to  be  positive  for  ma- 
laria, and  75.7  per  cent  proved  to 
be  positive  for  hookworm  disease. 
Of  the  64.8  per  cent  who  were 
negative  for  malaria,  77.5  per 
cent  were  positive  for  hookworm 
disease.  Of  the  75.7  per  cent 
who  were  positive  for  hookworm 
disease,  33.7  per  cent  were  posi- 


i  r 


POSITIVE  TO  BOTH  HOOKWORM  DISEASE  AND  MALARIA 

I3S3NEGATIYE  TO  BOTH  HOOKWORM  DISEASE  AND  MALARIA 
•POSITIVE  TOHOOKWORM  DIS£ASE;NEGATIVE  TO  MALARIA 
[JS3PQSITIVETOMALARIA.NEGATOETOHOOKWOIWISEASE 


PERSONS 


EXAMINED  EXAMINED 


2261 


PERSONS 


437 


PERSONS  PERSONS 
EXAMINED  EXAMINED 


98 


1726 


Fig.  59. — Correlation  between  in- 
tensity of  enlarged  spleens  and  pre- 
vious residence  in  malarious  locality. 
Spleen  examinations  at  Port  Swet- 
tenham.  (Table  33) 


Fig.  58. — Rates  of  malaria  and 
hookworm  infection  among  Chi- 
nese, Tamil,  and  Bengalese  pa- 
tients; 522  cases  at  District  Hos- 
pital, Kuala  Lumpur.  (Table  32) 

tive  for  malaria  also.  Of  the 
24.3  per  cent  who  were  negative 
for  hookworm  disease,  40.2  per 
cent  were  positive  for  malaria. 
It  is  thus  evident  that  there  was 
a  high  degree  of  malaria  infec- 
tion among  those  who  came  for 
treatment.  (See  Tables  31  and 
32,  pages  154  and  155.) 

Spleen  Examinations  at 
Port  Swettenham.  At  Port 
Swettenham,  2,261  coolies  were 
examined  with  reference  to  the 
possible  presence  or  absence  of 
spleen  enlargement;  a  total  of 
130,  or  5.7  per  cent,  enlarged 
spleens  were  found.  Among  the 
1,726  persons  who  had  never 
before  been  out  of  India,  60, 
or  3.5  per  cent,  had  enlarged 
spleens.  Among  the  437  who 
had  a  record  of  previous  resi- 
dence in  the  Federated  Malay 


FINDINGS   CONCERNING  MALARIA 


States,  59,  or  13.5  per  cent,  had  enlarged  spleens.  (See  Table  33, 
page  156.)  The  size  of  the  spleen  was  classified  as  being  negative, 
palpable,  one  finger's  breadth  below  the  ribs,  two  fingers'  breadth 
below  the  ribs,  three  fingers'  breadth  below  the  ribs,  one  hand's 
breadth  below  the  ribs,  or  to  the  pelvis. 

Additional  examination  of  150  children  under  12  years  of  age 
proved  that  only  5  had  enlarged  spleens;  thus  the  spleen  rate  among 
these  children  was  3.3  per  cent. 

Blood  Examinations  at  Port  Swettenham.  Immigrants  at 
Port  Swettenham  were  examined  for  evidence  of  plasmodia  in  the 
blood.  In  a  series  of  cases  examined  in  1915,  the  percentage  of  those 
found  positive  was  5.2  among  the  189  who  had  never  before  been 
out  of  India,  and  9.7  among  those  who  had  a  history  of  previous 
residence  in  the  Federated  Malay  States. 

Among  a  series  of  cases  examined  in  1916  the  parasite  rate  was 
found  to  be  3.4  per  cent  among  those  who  had  never  been  out  of 
India  before,  and  12.5  per  cent 
among  those  who  had  a  history 
of  previous  residence  in  the  Fed- 
erated Malay  States.  The  dif- 
ference between  the  percentage 
in  the  1916  series  and  that  in  the 
1915  series  is  small,  the  percent- 
age in  the  1916  series  being  but 
2  per  cent  less  than  that  in  the 
1915  series.  This  difference  may 
be  due,  at  least  in  part,  to  a 
selection  of  cases  with  enlarged 
spleens  in  the  1915  series.  (See 
Table  34,  page  157.) 

Blood  Examinations  in 
Malaya.  In  the  course  of  the 
Commission's  work,  altogether 
2,712  cases  were  examined  for 
plasmodia  in  the  blood:  677  at 
the  quarantine  camps  at  Port 
Swettenham  and  Singapore;  533 
at  two  jails;  168  at  six  schools; 
661  at  two  hospitals;  404  on  14 
rubber  estates;  162  at  a  tin 
mine;  and  108  whose  occupation 
was  in  connection  with  the 
public  works  department.  Of  this  total  number  (i.  e.  2,712),  463,  or 
17.1  per  cent,  were  found  positive  for  malaria  parasites  in  the  blood. 
Of  the  463  mentioned,  82  showed  subtertian  rings  alone;  56  showed 
subtertian  rings  and  crescents;  74  showed  crescents  alone;  128  showed 
benign  tertian  alone;  109  showed  quartan  alone;  7  showed  benign 
tertian  and  crescents;  3  showed  quartan  and  crescents;  2  showed  sub- 
5 


Fig.  60. — Correlation  between 
malaria  plasmodia  and  former  resi- 
dence, splenic  condition,  and  age  of 
patient.  Blood  examinations  at 
Port  Swettenham.  1915.  (Table  34) 


68 


INTERNATIONAL  HEALTH   BOARD 


tertian  and  benign  tertian;  and  1  showed  benign  tertian  and  quartan. 
The  decided  preponderance  of  subtertian  rings  in  the  type  of  para- 
site was  very  noticeable.  The  large  number  of  hospital  cases  tended 
to  increase  the  malaria  incidence  of  the  total,  but  an  examination 
of  the  separate  groups  showed  that  malaria  was  present,  to  a  con- 
siderable degree,  in  cases  not  seeking  hospital  aid. 

Malaria  Survey  at  Port  Swettbnham,  A  comparison  of  the 
hemoglobin  percentage  of  those  who  had  never  left  India  before, 
with  those  who  had,  as  shown  in  Table  35,  page  159,  would  seem  to 
indicate  that  the  degree  of  anemia  found  was  due  to  residence  in 
malarious  countries — in  other  words,  that  the  anemia  found  was 
malarial  in  origin. 

A  malaria  survey  was  conducted  in  the  neighborhood  of  the  quar- 
antine camp  at  Port  Swettenham.  Very  few  adult  anophelines  were 

caught  in  the  camp,  and  of  those 

that  were  caught  only  compara- 
tively few  were  found  within  a 
radius  of  one-half  mile,  except 
in  one  particular  locality.  Some 
150  females  caught  were  dis- 
sected and,  of  these,  two  were 
found  with  sporozoites  in  the 
salivary  glands. 

The  area  between  the  nearest 
large  breeding-place  and  the 
camp  was  inhabited,  and  the 
houses  may  have  acted  as  a 
screen  to  the  camp  itself.  At 
any  rate,  as  far  as  A.  ludlowi 
and  A.  rossi  were  concerned, 
two  other  large  breeding-places 
of  these  species  were  located  in 
the  immediate  vicinity  of  houses 
within  the  coolie  lines.  These 
probably  proved  a  greater  at- 
traction to  the  anophelines  than 


Fig.  61. — Correlation  between 
hemoglobin  rate  and  incidence  of  en- 
larged spleen.  Examined  for  malaria 
at  Port  Swettenham.  (Table  36) 


the  camp,  which  was  situated 
about  half  a  mile  away.  The 
main  breeding-place  for  A.  um- 
brosus  was  found  to  be  located 

about  one  and  one-half  miles  from  the  camp  at  Port  Swettenham,  and 
many  houses  intervened  between  the  breeding-place  and  the  camp. 

During  the  period  of  the  malaria  survey,  215  adult.4.  umbrosus,  36 
A.  rossi,  42  A.  ludlowi,  and  3  A.  kochi  were  caught  within  a  radius  of 
approximately  one-half  mile  from  the  camp.  Within  a  radius  of  one 
mile  from  the  camp,  in  the  houses  located  in  the  different  sec- 
tions of  Port  Swettenham,  1,068  A.  umbrosus,  176  A.  rossi,  74  A. 
ludlowi,  63  A.  kochi,  1  A.  tessellatus,  and  1  A.  kawari  were  found. 


FINDINGS   CONCERNING  MALARIA  69 

From  the  evidence  obtained  during  the  survey  it  may  be  concluded 
that  the  possibility  of  malaria  infection  of  coolies  in  the  camp 
at  Port  Swettenham  cannot  be  excluded.  A  comparison  of  the  blood 
examination  of  groups  with  different  lengths  of  residence  in  the  camp, 
indicates  that  infection  was  taking  place  to  a  very  small  extent,  if 
at  all,  at  the  time  of  the  examination  (August,  1916).  The  coolies 
who  were  examined  at  Port  Swettenham  during  the  period  from  Sep- 
tember to  December,  1915,  showed  little  or  no  malaria  when  they 
were  subsequently  re-examined  on  healthful  estates.  From  that  fact 
it  is  safe  to  conclude  that  malaria  infection  of  coolies  at  the  camp  at 
Port  Swettenham  occurred  in  a  very  small  degree,  if  at  all,  during 
periods  of  examination  of  coolies  there. 

The  fairly  close  relationship  between  the  percentage  of  palpable 
spleens  and  the  amount  of  anemia,  indicated  by  the  percentage  of 
hemoglobin  found,  is  shown  in  Table  36,  page  160. 

Malaria  Survey  on  Estates.  A  malaria  survey  of  each  estate 
visited  and  of  its  immediate  environment,  was  made  during  the  course 
of  investigations.  One  estate  would  be  found  to  be  located  on  a  flat 
coastal  plain  with  no  uncleared  jungles,  no  springs,  and  no  hillside 
seepage,  and  therefore  properly  to  be  described  as  non-malarious. 
Another  estate  would  be  found  to  be  decidedly  hilly,  with  many 
springs  and  streams  flowing  from  the  hillsides.  On  such  an  estate, 
the  seepage  would  create  swamps  and  other  propagation  areas 
for  mosquitoes.  A  locality  like  this  would  be  properly  described 
as  a  most  malarious  estate.  In  the  course  of  the  malaria  survey 
such  anophelines  as  were  known  carriers  of  malaria  (e.  g.  An- 
opheles maculatus)  were  caught,  and  the  females  were  dissected 
for  evidence  of  infection.  The  malaria  surveys  on  these  several 
estates  went  to  show  that  those  in  the  interior,  of  a  hilly  nature 
like  that  described,  where  there  was  an  absence  of  anti-malaria 
measures,  were  more  malarious  than  those  on  the  level  coastal 
plains.  The  latter  had  been  cleared  of  jungles  and  drained,  and 
were  therefore  relatively  free  from  malaria — except  where  prop- 
agation areas  were  found  for  A.  ludlowi,  which  is  a  known 
carrier. 

A  group  of  9  children  on  one  estate  was  especially  examined  for 
hookworm  disease,  and  it  was  found  that  among  them  4.5  times  as 
many  worms  were  harbored  in  cases  with  as  low  an  average  of  hemo- 
globin as  42.9  per  cent  as  in  cases  which  showed  as  high  an  average 
as  82.2  per  cent.  These  cases,  it  should  be  explained,  were  found 
on  the  flatland  estates  where  the  incidence  of  malaria  is  low. 

All  the  surveys,  investigations,  and  treatments  on  the  fourteen 
estates  visited  were  made  during  the  year  1916.  These  several  es- 
tates were  visited  from  30  to  40  weeks  after  the  examinations  at 
Port  Swettenham  or  at  Singapore.  The  estates  selected  were,  as 
has  already  been  explained,  those  on  which  were  to  be  found  the 
coolies  that  had  been  either  examined  or  treated  at  one  of  those 
ports.  As  many  as  possible  of  these  coolies  were  re-examined  for 


70 


INTERNATIONAL   HEALTH    BOARD 


evidence  of  exposure  to  malaria  and   for   indications  of   changes   in 
hemoglobin. 

It  was  discovered  that  there  was  an  average  gain  of  3.2  per  cent 
hemoglobin  among  234  coolies  who  entered  the  ports  free  from  ma- 
laria but  infected  with  hookworm  disease.  There  was  an  average 
gain  of  8.4  per  cent  in  162  cases  that  contracted  no  malaria  after 
entering  the  Federated  Malay  States,  and  an  average  loss  of  8.6 
per  cent  in  the  72  cases  that  did  contract  it.  A  combination  of  these 
last  two  figures  would  indicate  that  residence  in  the  Federated  Malay 
States  should  normally  result  in  a  gain  of  17  per  cent  in  the 
hemoglobin  content.  Normal  expectancy  of  gain  is  probably 

attributable  to  the  better  wages 
and  the  better  food  which  the 
workers  enjoy  in  the  country  of 
their  temporary  adoption.  It 
was  perfectly  clear  that  the 
tendency  to  gain  hemoglobin 
was  much  affected  by  malaria. 
As  between  those  who  did,  and 
those  who  did  not,  contract 
malaria  during  their  period  of 
residence  in  the  Federated 
Malay  States,  there  was  a 
difference,  in  the  average  gain, 
of  17  per  cent  hemoglobin  per 
case.  As  between  those  who 
did,  and  those  who  did  not, 
contract  hookworm  infection 
during  their  residence  in  the 
Federated  Malay  States,  there 
was  a  difference  of  16.8  per  cent 
average  gain. 

Tables  37,  38,  39,  and  40, 
pages  161  to  164,  show  the  re- 
sults of  the  findings  of  coolie 
re-examinations  on  the  several 
estates.  Table  37  gives  the 
changes  in  hemoglobin  (for  all 
the  estates  that  were  visited) 
by  coolies  who  were  free  from  malaria  but  infected  with 


Fig.  62. — Gain  or  loss  in  hemo- 
globin after  residence  on  estates. 
Re-examination,  on  estates,  of 
coolies  found  free  of  malaria  but 
infected  with  hookworm  disease  on 
arrival  at  Port  Swettenham.  (Tables 
37  and  38) 


shown 

hookworm  disease  on  arrival  at  Port  Swettenham. 

First,  as  to  the  cases  with  evidence  of  malaria  after  arrival,  Table 
37  indicates  that  the  28  cases  treated  for  hookworm  at  Port  Swetten- 
ham showed  an  average  loss  of  5.7  per  cent  hemoglobin.  The  aver- 
age loss  of  the  44  cases  not  treated  at  Port  Swettenham  was  10.4 
per  cent  hemoglobin;  the  average  loss  for  the  total  of  72  cases,  irre- 
spective of  treatment,  was  8.6  per  cent  hemoglobin.  Therefore,  the 
benefit  due  to  treatment  for  hookworm  in  the  malaria  cases  was 


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FINDINGS   CONCERNING   MALARIA 


73 


4.7  per  cent,  or  the  difference  between  the  loss  shown  by  the  treated 
cases  and  that  shown  by  the  cases  that  were  not  treated. 

Next,  concerning  the  cases  with  no  evidence  of  malaria  after 
arrival,  the  table  indicates  that  the  41  cases  treated  at  Port  Swet- 
tenham  showed  an  average  gain  of  15.2  per  cent  hemoglobin. 
The  average  gain  of  the  121  cases  not  treated  at  Port  Swetten- 
ham  was  6  per  cent  hemoglobin;  the  average  gain  for  the  total  of 
162  cases,  irrespective  of  treatment,  was  8.4  per  cent  hemoglobin. 
Therefore,  the  benefit  due  to  treatment  in  the  non-malaria  cases 
was  9.2  per  cent,  or  the  difference  between  the  gain  shown  by  the 
treated  cases  and  that  shown  by  the  cases  that  were  not  treated. 

As  for  the  gain  due  to  treatment,  irrespective  of  malaria,  Table  37 
indicates  that  the  69  cases  treated  at  Port  Swettenham  showed  an  aver- 
age gain  of  6.7  per  cent  hemoglobin.  The  average  gain  of  the  165 
cases  not  treated  at  Port  Swettenham  was  1.6  per  cent  hemoglobin. 
Therefore,  the  gain  due  to  treatment  was  5.1  per  cent  hemoglobin. 

Table  38  gives  a  detailed  account  of  the  changes  in  hemoglobin, 
on  all  the  estates  that  were  visited,  shown  by  the  19  coolies  who  had 
evidence  of  malaria  on  arrival  at  Port  Swetten- 
ham. The  table  indicates  that  the  average 
gain  in  hemoglobin  of  the  total  of  12  cases 
showing  evidence  of  malaria  on  the  estates  as 
well  as  at  Port  Swettenham,  was  10.6  per  cent. 
The  average  gain  in  hemoglobin  of  the  7 
cases  without  evidence  of  malaria  on  the 
estates,  was  16.6  per  cent;  the  average  gain  of 
the  5  cases  that  were  treated  at  Port  Swetten- 
ham was  15.8  per  cent;  the  average  gain  of 
the  14  cases  that  were  not  treated  at  Port 
Swettenham  was  11.7  per  cent. 

From  these  data  it  will  be  seen  that  the 
cases  with  evidence  of  malaria  on  arrival  at 
Port  Swettenham  do  not  show  the  loss  in  hemo- 
globin shown  by  the  cases  arriving  free  from 
ma'laria.  On  the  other  hand,  the  cases  that 
do  not  show  evidence  of  malaria  on  the  estates 
show  a  greater  rise  in  hemoglobin  than  the 
cases  that  still  show  evidence  of  malaria. 
There  is  a  slight  benefit  in  treatment  demon- 
strable in  this  series  of  cases  as  well  as  in 
the  series  which  was  shown  to  be  free  from 
malaria  on  arrival  at  Port  Swettenham. 

Table  39  shows  what  happened  with  regard  to 
the  hemoglobins  of  the  twelve  cases  which  were 
traced  to  estates,  and  which  were  shown  to  be 
free  of  both  malaria  and  hookworm  disease  at 
Port  Swettenham.  The  figures  in  the  table  in- 
dicate that  all  the  cases  showed  a  loss  of  hemo- 


20 


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L.J  </> 


Fig.  65  .—Gain  or  loss 
in  hemoglobin  after 
residence  on  estates. 
Re -examination  of 
coolies  free  of  ma- 
laria and  hookworm 
disease  on  arrival  at 
Port  Swettenham. 
(Table  39) 


74 


INTERNATIONAL   HEALTH    BOARD 


globin  even  when  they  did  not  contract  malaria.  This  was  proba- 
bly due  to  the  fact  that  they  became  infected  with  hookworm  disease, 
for  the  five  cases  that  did  not  contract  malaria  went  to  a  flatlands 
estate  where  hookworm  disease  was  proved  to  be  an  important  factor 
in  causing  debility. 

Table  40  is  a  summary  of  the  gains  or  losses  in  hemoglobin,  with  re- 
spect to  malaria,  of  all  the  coolies  found  on  each  estate.  When  all  the 
coolies  found  on  an  estate  are  taken  as  a  single  group,  and  the  gross 
average  change  in  hemoglobin  is  calculated — irrespective  of  treatment 

or  of  malaria — an  important  in- 
dex is  obtained  showing  the  rela- 
tive healthfulness  of  the  estates. 
In  the  table,  this  gross  average 
change  in  hemoglobin  is  com- 
pared with  the  number  of  cases 
showing  evidence  of  malaria,  and 
the  estates  are  arranged  in  the 
order  of  the  degree  of  change  in 
hemoglobin  found.  The  close  re- 
lationship between  the  change  in 
hemoglobin  and  the  number  of 
cases  showing  evidence  of  mala- 
ria, is  a  very  important  indication 
of  the  power  of  malaria  as  a  fac- 
tor in  the  production  of  anemia. 

Malaria  in  the  Java  Kam- 
pongs:  Relation  to  Hook- 
worm. In  the  course  of  the  work 
in  Java,  the  Commission  under- 
took to  asce'rtain  what  corre- 
Fig.  66  —Re-examination  of  267  spondence  there  was,  if  any,  be- 


coolies   after    residence   on  estates. 
Anemia  and  malaria.     (Table  40) 


tween  malaria  infection  and  the 
number  of  hookworms  harbored. 
The  Java  kampongs,  or  compounds,  may  be  divided  into  three  classes 
with  respect  to  malaria:  (1)  those  highly  malarious,  (2)  those  free,  or 
nearly  free,  from  malaria;  and  (3)  those  with  a  few  cases  of  malaria. 
Among  patients  residing  in  the  first  class  of  kampong,  the  spleen  rates 
were  high,  while  the  worm  counts  were  not.  In  Jaagpad,  for  exam- 
ple, the  spleen  rate  was  91.9  (100  in  the  treatment  squad),  and 
the  average  number  of  hookworms  harbored  was  34.4.  At  Gebon- 
gelir  the  spleen  rate  was  97.0,  and  the  average  number  of  worms 
harbored  was  46.7.  At  Endil  the  spleen  rate  was  87.6,  and  the 
average  number  of  worms  harbored  was  51.  In  these  dessas,  or  vil- 
lages, it  was  apparently  impossible  to  ascertain  what  influence  either 
infection  had  on  the  other  (malaria  or  hookworm)  for  practically 
the  entire  population  was  infected  with  both  malaria  and  hookworm 
disease.  Malaria  always  caused  the  greater  amount  of  anemia,  for 
the  reason  that  the  hookworm  infections  were  usuallv  mild. 


Fig  67. — People  of  Batavia  treated  at  Kampong  Kramat. 
Spleen  rate,  11.4%;  plasmodia,  negative;  hookworm  inci- 
dence, 100%;  average  number  of  worms  per  individual,  45 


Fig.  68. — Two  cases  of  hookworm  infection  in  the  highly 
malarious  Kampong  of  Jaagpad,  Java.  The  man  had  54 
worms;  hemoglobin,  5%;  spleen,  3  fb.  below  costal  margin; 
blood  contained  malignant  tertian  plasmodia.  The  girl  had 
11  worms;  hemoglobin,  67%;  spleen,  2  fb.  below  umbilicus; 
blood  showed  polychromasia  but  no  plasmodia  at  the  time 


Fig.  69. — A  prolific  breeding  place  in  brackish  water  for 

the  anophelines  which  spread  malaria  in  the  kampongs  of 

Batavia  near  the  sea 


METERS 
FROM 
SEA 

1 

IN 

ALARIA 
FECTION 

100 
90 
80 
70 
60 
50 
40 
30 
20 

10 
n 

JAAC 

<^500 

PAD 

91.1 

x 

-AT  BATAV 
500  Meters 
66  ? 

X 

^S.    DJIMBATAN  LIM> 
_V   2  400  Meters 

\ 

53.9 

\ 

\ 

\    SAWA 

*  , 

H  BESAR 

_          3400 

Maters 

6.600 

Meters 
11.4 

)              1,000           2,000           3,000           4,000           5,000           6,000           7,000 

Fig.  70. — Correlation  between  incidence  of  malaria  infec- 
tion and  distance  from  the  sea.     Spleen  rates  vary  in- 
versely with  the  distance 


FINDINGS    CONCERNING   MALARIA 


77 


In  Kalimaro,  Kebasekan,  and  Krakal,  on  the  other  hand,  there 
was  little  or  no  malaria,  and  the  worm  counts  were  high — Kalimaro 
197.5  and  Kebasekan  168.0  per  person.  These  figures  are  about 
three  or  four  times  as  high  as  those  obtained  in  the  malarious  dessas, 
and  the  number  of  persons  with  palpable  or  enlarged  spleens  was  too 
small  for  the  data  to  afford  any  basis  for  an  estimate  as  to  the  possible 
influence  of  one  infection  on  the  other. 

The  figures  obtained  in  Batavia  kampongs  and  in  the  jail,  however, 
perhaps  furnish  some  basis  for  comparison.  The  entire  city  may  be 
regarded  as  urban,  although,  as 
explained  elsewhere,  the  natives 
live  in  their  kampongs  within 
the  city  limits.  In  the  city 
there  is  less  soil  pollution,  how- 
ever, than  in  the  strictly  rural 
districts.  Near  the  sea  there  is 
severe  malaria,  but  the  incidence 
diminishes  as  the  distance  from 
the  sea  increases.  It  is  therefore 
possible  to  compare  the  inci- 
dence of  hookworm  infection 
and  of  malaria  in  the  four  kam- 
pongs. The  figures  of  such  a 
comparison  are  shown  in  Table 
41,  page  165.  It  will  be  seen 
from  this  table  that  there  is 
a  considerably  larger  average 
number  of  worms  in  the  group 
with  enlarged  spleens  than  in 
the  negative-spleen  group. 

Malaria  in  Java  Jail:  Re-  Fig.  71. — Relationship  between 
lation  of  Worms.  Given,  as  splenic  condition  and  number  of 
positive  evidences  of  malaria,  hookworms  harbored.  Eighty-three 

the    presence    of    plasmodia   in    Persons    trefTed    iorf£°?^m   m 

.,1,1  ,    kampongs  of  Java.     (Table  41) 

the   peripheral   blood,   enlarged 

spleens,  or  both,  and  as  negative  evidences  the  absence  of  plasmodia, 
and  conditions  showing  the  spleen  neither  enlarged  nor  palpable, 
the  treated  cases  in  Penal  Institution  No.  3  may  be  divided  into 
the  six  following  groups: 

Group      I — Spleen  palpable — Plasmodia  present 


Group  II — 
Group  Ill- 
Group  IV — 
Group  V — 
Group  VI— 


enlarged — 
palpable — 
enlarged — 
negative — 
negative — 


present 

absent 

absent 

present 

absent 


Groups  I,  II,  III,  IV,  and  V  contain  all  the  cases  with  positive  evi- 
dences of  malaria  at  the  time  of  examination.     Group  VI  contains 


INTERNATIONAL   HEALTH    BOARD 


the  cases  with  negative  evidences — that  is,  evidences  showing  active 
malaria  to  be  absent — for  it  is  understood  that  all  the  prisoners  are 
constantly  exposed  to  severe  malaria  infection.  In  the  aggregate, 
however,  only  a  certain  limited  number  of  men  at  any  given  time 
exhibit  evidences  of  active  malaria — plasmodia,  fever,  and  spleen 
enlargement. 

Reference  to  Table  42,  page  166,  will  show  that  the  average  hemo- 
globin for  the  malarial  groups  was  66.9  per  cent,  and  for  the  non- 
malarial  group  81.2  per  cent,  while  the  average  number  of  worms  in 

the  former  groups  was  98.4  and 
in  the  latter  group  54.8.  Thus 
it  would  appear  that  in  this  jail 
there  was  a  correlation  between 
the  presence  of  malaria  and  the 
number  of  worms. 

It  must  be  remembered  that 
the  men  were  constantly  exposed 
to  malaria  infection  and  were 
in  a  state  of  inconstant  flux  with 
regard  to  it — men  suffering  from 
the  disease  one  month  being 
apparently  free  from  it  the 
next.  This  condition  was  dem- 
onstrated at  the  jail  by  the  con- 
dition of  men  whose  spleen  and 
blood  were  negative,  but  who 
succumbed  to  malaria  within  a 
few  days  after  admission  to  the 
ward,  and  also  by  the  diminu- 
tion in  size  of  spleens  in  malaria 
cases  at  the  time  of  re-examina- 
tion after  several  weeks. 

It  is  also  demonstrably  true 
that  the  prisoners  were  not 
acquiring  new  hookworm  infec- 


|  AVERAGE  HEMOGLOBIN^ER  CENT) 
|  HOOKWORMS  HARBORED^WERAGE  N(j) 


Fig.  72. — Correlation  between 
presence  of  malaria  and  number  of 
hookworms  harbored.  Eighty-eight 
cases  in  Java  j  ail.  (Table  42) 


tions;  their  respective  complements  of  worms  were  brought  in  with 
them.  In  fact,  there  was  a  tendency  for  them  to  lose  worms  the  longer 
they  stayed  in  prison.  The  more  severe  cases  of  hookworm  infection, 
as  well  as  some  other  hookworm  cases,  were  probably  weeded  out  by 
treatment,  for  about  10  per  cent  of  the  men  in  the  treatment  squads  had 
been  treated  with  chenopodium  in  the  hospital  adjoining  the  jail. 

Under  these  circumstances,  the  underlying  causes  that  have  led  to 
a  correlation  between  low  worm  counts  and  negative  spleens  are  not 
known.  Perhaps  a  better  idea  of  the  situation  may  be  obtained  if  the 
cases  are  analyzed  with  special  regard  to  the  relation  of  worms  to 
plasmodia,  as  is  done  in  Table  43,  page  167. 

The  following  points  should  be  noted:  (1)  the  higher  average  worm 
counts  were  encountered  in  the  groups  in  which,  at  the  time  of  exami- 


FINDINGS   CONCERNING   MALARIA 


79 


nation,  plasmodia  were  absent 
but  in  which  spleens  were  either 
palpable  or  enlarged;  (2)  lower 
average  worm  counts  were  found 
when  plasmodia  were  associated 
withenlargedorpalpable  spleens; 
(3)  the  lowest  average  worm 
counts  were  found  when  plasmo- 
dia were  absent  and  the  spleens 
were  negative;  (4)  the  anemia  is 
correlated,  not  with  the  presence 
or  absenceof  plasmodia, butwith 
a  palpable  or  enlarged  spleen. 

In  one  of  the  squads  the  exam- 
ination of  blood  for  plasmodia 
was  not  made,  but  there  were 
eighteen  cases  which  may  be 
analyzed  with  regard  to  splenic 
enlargement,  number  of  worms, 
hemoglobin,  and  length  of  time 
in  prison. 

In  Table  44,  page  168,  which 
includes  these  eighteen  cases  in 
addition  to  the  other  treatment 


•  AVERAGE  HEMOGLOBIN  (PERCENT) 
^HOOKWRMS  HARBORED  (AVERAGE  NUMBER) 


Fig.  73. — Relationship  between 
number  of  hookworms  harbored  and 
presence  or  absence  of  malaria  plas- 
modia. Eighty-eight  cases  in  Java 
jail.  (Table  43) 

squads,  it  will  be  seen  that  there 
is  a  very  marked  positive  correla- 
tion between  enlarged  spleens  and 
number  of  worms,  and  that,  as 
regards  this  correlation,  the 
palpable  spleen  occupies  a 
place  intermediate  between  the 
negative  spleen  and  the  en- 
larged spleen. 

There  seems,  however,  to  be 
little  or  no  correlation  between 
plasmodia  and  worms,  when 
cases  are  taken  irrespective  of 
the  condition  of  the  spleen. 
The  average  number  of  worms 
associated  with  plasmodia  was 
76.7  and  the  number  of  pa- 
tients with  plasmodia  absent 
at  the  time  of  examination 
was  74.  (See  Table  43.)  In 


Fig.  74.— Correlation  between  splenic 


condition  and  number  of  hookworms  the  negative-spleen  group,  how- 
harbored.  One  hundred  six  cases  in  ever,  there  was  a  positive  cor- 
Javajail.  (Table  44)  relation  between  plasmodia  and 


8o 


INTERNATIONAL   HEALTH    BOARD 


worms.  Anemia  was  also  posi- 
tively correlated  with  worms 
and  splenic  enlargement. 

The  degree  of  splenic  enlarge- 
ment increased  with  the  dura- 
tion of  exposure  to  malaria 
infection,  and  in  the  negative- 
spleen  group  the  presence  of 
plasmodia  was  negatively  corre- 
lated with  length  of  exposure  to 
malaria.  It  is  to  be  inferred, 
therefore,  (1)  that  plasmodia 
are  more  apt  to  be  demonstrated 
in  the  earlier  periods  of  jail 
residence,  (2)  that  splenic  en- 
largement occurs  with  greater 
frequency  in  the  later  periods 
of  residence,  and  (3)  that  the 
men  receive  in  the  jail  more 
malaria  than  they  bring  in. 

This  is  borne  out  by  the 
observation  that  92  prisoners 
confined  from  1  to  3  months  had 
an  average  hemoglobin  of  83.5 
per  cent,  while  the  average  of 


I  TO  5  MONTHS  JAIL  RESIDENCE 
TO  72  MONTHS  JAIL  RESIDENCE 


Fig.  76. — Splenic  enlargement  in 
relation  to  length  of  jail  residence; 
594  cases  in  Java  jail.  (Table  46) 


Fig.  75. — Hemoglobin  rate  and 
degree  of  splenic  enlargement  in 
relation  to  length  of  jail  residence; 
115  cases  in  treatment  squads  in 
Java  jail.  (Table  45) 

the  total  (594)  was  77.1  per 
cent.  (See  Table  45,  page  169.) 
Furthermore,  of  25  men  who 
had  been  in  the  jail  for  periods  of 
nine  days  and  under,  and  who  re- 
ceived examination,  16  had  neg- 
ative, 4  palpable,  and  5  enlarged 
spleens — a  spleen  rate  of  36. 
This  splenic  enlargement  must 
have  been  brought  in  with  them. 

The  frequency  of  splenic  en- 
largement increases  markedly 
during  the  first  6  months  of 
jail  residence.  (See  Table  46, 
page  170.) 

The  correspondence  between 
splenic  enlargement  and  high 
average  worm  count,  so  far  as 
this  jail  is  concerned,  may  be 
explained  by  the  fact  that  men 
free  from  malaria  come  into  the 
jail  from  regions  where  there  is 
little  or  no  malaria,  but  where 


FINDINGS   CONCERNING   MALARIA  8 1 

there  is  considerable  hookworm  infection.  The  men  with  high 
worm  counts  and  anemia  might  be  more  liable,  after  malaria  infec- 
tion, to  acquire  and  retain  a  degree  of  splenic  enlargement.  Here 
it  would  seem  possible  that  hookworm  infection  with  anemia  might 
render  a  person  more  susceptible  to  malignant  influences  of  malaria 
— in  the  case  of  those  free  from  malaria  and  harboring  a  large 
number  of  worms,  who  take  up  residence  in  a  malarious  locality  and 
become  infected  with  malaria.  But  we  should  not  eliminate,  in 
considering  the  series,  the  possibility  of  cases  occurring  which,  pre- 
vious to  entrance,  already  had  a  large  complement  of  worms,  owing  in 
part  to  the  lowering  of  resistance  to  hookworm  re-infection  by 
attacks  of  malaria. 

Control  Investigations  in  the  Fiji  Islands.  It  was  clear 
to  the  Commission  that,  for  the  purpose  of  control  facts  and 
figures,  it  would  be  necessary  to  study  conditions  in  some  com- 
munity known  to  be  free  from  malaria  in  an  endemic  form.  While 
it  is  true  that  hookworm  infection  is  universal  in  the  tropics,  mala- 
ria is  not  co-extensive  with  it.  For  instance,  Barbados  is  free  of 
malaria;  the  same  is  probably  true  with  respect  to  some  of  the 
estates  on  the  flatlands  of  the  Federated  Malay  States,  and  some 
districts  in  Java  and  Sumatra.  But  it  was  deemed  desirable,  in 
order  to  eliminate  all  doubt,  to  make  the  control  investigations  in 
some  of  those  islands  of  the  Pacific  which  were  known  to  be  en- 
tirely free  from  endemic  malaria.  This  condition  prevails  among 
the  islands  of  the  Fiji  Archipelago.  It  will  be  remembered  that 
the  investigation  in  the  Federated  Malay  States  had  been  made 
among  the  coolies  from  South  India.  Therefore,  inasmuch  as  many 
Indians,  both  free  and  indentured,  were  to  be  found  in  the  Fiji 
Islands,  the  conclusion  was  reached  by  the  Commission  that  no 
better  place  for  making  the  control  studies  could  be  found. 

The  observations  of  the  Commission  were  confined  to  the  largest 
island  in  the  Archipelago,  Viti  Levu — to  territory  on  the  south  side 
of  this  island  and,  for  the  most  part,  in  and  around  the  town  of 
Nausori,  and  among  the  coolies  living  on  the  plantations  along  the 
Rewa  River.  Both  the  native  Fijians  and  the  Indians  examined 
here  were  apparently  in  good  physical  condition.  The  indentured 
Indians  were  in  rather  better  condition  than  the  free,  or  time- 
expired,  coolies. 

The  work  was  begun  with  a  preliminary  malaria  survey.  Groups 
were  assembled  and  clinically  examined  for  evidence  of  enlargement 
of  the  spleen  and  for  clear  indications  as  to  hemoglobin  content. 
Like  groups  were  then  carefully  tested  for  hemoglobin  percentages, 
and  blood  examinations  were  made  for  the  purpose  of  discovering 
any  direct  evidence  of  malaria.  This  work  was  conducted  as  follows: 
among  the  persons  in  the  Colonial  jail  at  Suva;  among  the 
indentured  Indians  working  in  the  sugar  factory  at  Nausori; 
among  both  the  indentured  and  the  free  Indian  shopkeepers  and 
artisans  working  in  the  village  of  Nausori;  among  the  Fijian 


82  INTERNATIONAL  HEALTH    BOARD 

youths,  practically  all  of  whom  were  either  sons  of  chiefs  or  else  from 
some  of  the  other  high-caste  families,  attending  the  Queen  Victoria 
School;  among  Fijian  men,  women,  and  children  in  the  villages  of 
Nausori  and  Vanimora  (both  river  towns);  among  Fijian  men, 
women,  and  children  in  the  village  of  Nasaqo  (which  is  a  mountain 
town);  and  among  European  men,  women,  and  children  in  the  village 
of  Nausori. 

Of  the  529  who  were  examined  for  indications  of  malaria  plas- 
modia,  297  were  Indians,  158  were  Fijians,  and  the  rest  were  Euro- 
peans— half-castes  and  Polynesians  of  all  ages  and  both  sexes.  In 
the  examinations  for  indication  of  blood  parasites — plasmodia  and 
filaria — thick  film  stains,  obtained  by  modification  of  Hasting's 
stain,  were  employed.  None  of  those  examined  were  found  to  be  posi- 
tive for  plasmodia  and,  respecting  all  those  examined  for  enlarged 
spleens,  only  5  palpable  spleens  were  found  among  57  patients  exam- 
ined at  the  Suva  Hospital,  1  among  the  64  boys  examined  at  the  Queen 
Victoria  School,  and  6  (all  in  the  case  of  North  Indians)  among  the 
885  Indians  and  Fijians  who  were  examined  on  the  plantations  along 
the  Rewa  River,  near  Nausori  and  Nasaqo.  Careful  search  was 
made  near  Suva,  Nausori,  and  Nasaqo  for  anopheline  larvae,  but 
none  were  found. 

Clearly,  therefore,  malaria  was  not  found  endemic  in  the  districts 
visited  by  the  Commission,  and  the  medical  history  of  the  people — 
as  drawn  from  the  reports  of  the  Chief  Medical  Officer  and  from  con- 
versation with  medical  practitioners,  planters,  and  officials — together 
with  the  absence  of  anopheles,  convinced  the  Commission  that  the 
island  was  entirely  free  from  this  disease  in  an  endemic  form.  Par- 
oxysms of  malaria  are  said  to  attack  indentured  coolies  occasionally 
during  the  first  year  or  two  after  arrival  from  India,  but  no  evi- 
dences of  acute  or  chronic  malaria  were  found  in  any  of  the  more 
recently  arrived  indentured  coolies  examined  by  the  Commission. 
Nor  was  a  history  of  dysentery  obtained  in  more  than  two  or  three 
cases.  The  anemia  observed  may  therefore  be  properly  attributed 
to  the  effect  of  hookworm  infection,  intensified  more  or  less  in  certain 
classes  by  an  insufficiency  of  food. 


CHAPTER   VIII 

FINDINGS   CONCERNING  ANEMIA 

Hemoglobin  Standards  in  Relation  to  Race,  Age,  and  Sex. 

The  principal  question  to  which  the  Commission  was  expected  to  find 
an  answer  was,  "To  what  degree  is  Uncinaria  infection  a  menace  to 
the  health  and  working  efficiency  of  the  people  of  Malay?"  In 
order  to  answer  this  question  it  was  necessary  to  give  some 
relative  weight  or  value  to  hookworm  infection,  associated  as  it 
nearly  always  is,  with  malaria.  It  would  be  necessary  to  find  out  in 
any  given  community  the  degree  of  anemia  due  to  hookworm  infec- 
tion. The  damage  done  by  malaria  —  as  indeed  also  the  benefit 
derived  from  treatment  for  hookworm  infection — is  expressed  in 
terms  of  average  loss  or  gain  of  hemoglobin  per  individual.  It  is 
quite  clear,  then,  that  if  we  wish  to  state  to  what  degree  hookworm 
infection  is  a  menace  on  A.  B.  estate,  the  factor  may  be  best  expressed 
in  terms  of  lost  hemoglobin  per  individual.  But  if  we  wish  to  state 
to  what  degree  it  is  a  menace  on  X.  Y.  estate,  where  there  is  also 
severe  malaria,  it  is  a  problem  to  know  how  it  shall  be  estimated  and 
expressed. 

Individual  cases  of  infection,  it  was  found,  could  not  be  properly 
compared  on  account  of  the  unknown  factor  of  individual  resistance 
or  perfection  of  defense.  But  when  all  the  cases  were  bulked  and 
averaged  it  was  observed  that  there  was  some  correlation  between 
degrees  of  anemia  and  numbers  of  worms,  and  this  fact  led  to  the 
conclusion  that  it  would  be  possible  to  work  out  a  factor  which  would 
express,  if  only  crudely,  the  amount  of  anemia  caused  by  a  given 
number  of  worms.  However,  it  was  not  so  simple  a  matter  to  work 
out  this  factor,  as  several  difficulties  were  met  which  had  first 
to  be  overcome.  In  the  first  place,  it  was  found  impossible  to  estab- 
lish a  single  standard  of  hemoglobin  for  a  total  population.  A  fact 
not  generally  recognized  is  that  the  hemoglobin  differs  considerably 
in  the  two  sexes  and  in  the  different  periods  of  life,  and  yet  this  dis- 
parity is  so  marked  that  for  purposes  of  exact  comparison  groups  must 
be  considered.  Examination  of  large  numbers  of  apparently  normal 
people  disclosed  considerable  variation  from  the  average  which  exists 
through  all  the  decades  of  life  and  exhibits  a  marked  degree  of  con- 
sistency. 

A  fairly  large  number  of  individuals  were  examined  in  an  effort 
to  ascertain  the  hemoglobin  percentages  of  the  sexes  and  of  various 
races  at  different  periods  of  life.  Many  interesting  facts  were  brought 
out  by  these  examinations.  It  was  found,  for  instance,  that  age  influ- 
ences the  hemoglobin  values,  not  merely  during  adolescence  but  dur- 
ing the  entire  period  of  life,  so  that  different  values  must  be  assigned 
to  each  decade.  To  illustrate:  it  was  found  among  the  kampong 
people  that  the  highest  point  of  the  wave  was  reached  during  the  third 

83 


84  INTERNATIONAL   HEALTH    BOARD 

decade,  the  20-30  years  period.     The  lower  values  began  to  show 
themselves  in  the  next  decade.     After  the  fiftieth  year  a  very  decided 
drop  was  found  to  occur,  reaching  at  times  the  values  seen  in  early 
,  childhood. 

The  examinations  conducted  among  the  Tamil  coolies  at  Port 
Swettenham,  among  the  Chinese  coolies  at  St.  John's  Island  (Singa- 
pore), and  among  the  natives  of  Java  proved  conclusively  that  there 
was  a  very  marked  difference  between  the  hemoglobin  values  of  men 
and  the  hemoglobin  values  of  women.  At  Port  Swettenham,  with  the 
Dare's  instrument,  hemoglobin  determinations  were  made  on  2,261 
Tamil  coolies.  Of  the  1,659  men  thus  examined,  the  majority  showed 
a  hemoglobin  average  of  between  80  and  89  per  cent,  and  the  major- 
ity of  the  452  women,  and  150  children  under  12,  examined  showed  a 
hemoglobin  percentage  of  between  70  and  79.  In  other  words,  the 
average  hemoglobin  among  the  men  was  found  to  be  about  10  per 
cent  higher  than  among  the  women. 

It  was  found  that  the  effectof  pregnancyon  the  hemoglobinwas  very 
striking,  and  seemed  to  be  more  noticeable  in  the  later  months.  Again 
and  again  this  reduction  in  hemoglobin  value  due  to  pregnancy  was 
encountered,  oftentimes  amounting  to  as  much  as  15  per  cent  below 
that  of  the  normal  non-pregnant  women  of  the  kampong.  This  is 
probably  attributable  to  hydremic  plethora,  a  condition  which, 
although  normally  encountered  in  pregnant  women,  is  also  probably 
a  frequent  occurrence  after  puberty  in  non-pregnant  females  whose 
hematopoietic  system  is  overtaxed.  The  reason  for  this  explanation 
is  the  fact  that  a  number  of  women  were  found  who  were  suffering 
from  anemia,  and  in  whom  no  other  cause  of  anemia  could  be  elicited. 
Malaria  was  absent  at  the  time  of  examination,  and  the  number  of 
hookworms  was  too  inconsiderable  to  be  assigned  as  a  cause.  Obser- 
vations would  seem  to  indicate  that  females  are  very  much  more 
unstable  as  regards  their  reaction  to  an  anemia-producing  cause. 
(See  also  section  "Greater  Severity  of  Anemia  in  Women,"  page  115.) 
The  fact  that  a  very  large  proportion  of  the  women  were  found  preg- 
nant added  considerably  to  the  difficulties  of  the  Commission  in  deter- 
mining the  hemoglobin  standard  of  women. 

In  the  course  of  its  investigation  the  Commission  found  in  Java  a 
place  in  which  there  was  no  malaria.  Anthelmintic  treatment  of  a 
representative  group  of  the  dessa  people  disclosed  the  fact  that  very 
few  worms  were  harbored  by  them.  The  incidence  of  infection  as 
determined  by  treatment  was  52  per  cent,  and  the  average  number  of 
worms  per  individual  was  only  6.3.  Thirteen  men  whose  ages  ranged 
from  17  to  50  showed  an  average  hemoglobin  content  of  99.3  per 
cent.  Nineteen  children  whose  ages  ranged  from  5  to  14  showed  an 
average  hemoglobin  content  of  90.1  per  cent.  This  group  of  people, 
who  lived  and  worked  at  an  altitude  of  3,600  feet,  was  relatively  the 
freest  from  malaria  or  hookworm  infection  of  any  people  ;nvesti- 
gated  anywhere.  Four  of  the  men  treated  were  found  to  have  hemo- 
globin percentages  of  96,  98,  101,  and  104,  respectively.  Were  it  not 


Fig.  77. — Types  of  natives  in  treatment  squad  at  Tji- 
matjan,  Java.  Living  at  an  altitude  of  3,600  feet,  free 
from  malaria,  and  have  very  little  hookworm  infection. 
A  fine  sturdy  lot.  Spleen  and  parasite  rate,  nil;  hook- 
worm incidence,  52%;  average  hookworms,  6 


Fig.  78. — A    vigorous    dessa   man   carrying   his   plow   on 

his  shoulders  to  the  fields.     Hookworm  infection  in  the 

district  very  light 


rt 


IIC"3 

ft     O     C     c 

>  g  s  .2 

as     OJ      £      fti 


g 

•S  f 

^  o 

c3 

'g    g 


v 


c  .b 

'-"     3 


-1     O 


rt     3 


^  - 
<u   o 


^     ^    So 

'J~i      rt  rt     ! "  3 

•|   o  ^   j§   S  ^ 

t"1  c  ~cL  **^  o 

r-  <U  C3  C 

§  W      .^     OJ  C 

•^!  'C  d,^\  •+*  .2 

o    rt  «o  ii,    o 


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rt     00  *2 


FINDINGS   CONCERNING   ANEMIA 


for  the  fact  that  these  people  were  living  at  so  high  an  altitude,  to 
which  fact  their  higher  hemoglobins  could  conceivably  be  attributed, 
they  might  well  be  regarded  as  a  satisfactory  group  from  which  to 
derive  an  average  hemoglobin  standard. 

Control  determinations  of  hemoglobins  of  the  members  of  the  Com- 
mission were  made  at  the  time,  and  found  to  register  several  degrees 
lower  than  those  of  the  natives  infected.  The  average  hemoglobin  of 
the  members  of  the  investigating  party  was  found  to  be  87  per  cent, 
which  is  what  it  had  registered  at  sea  level  on  several  previous  occa- 
sions. It  was  therefore  thought  unwise  to  use  a  high  altitude  index 
as  a  standard  with  which  to  compare  people  living  at  or  near  sea  level. 

It  was  felt  by  the  Commission  to  be  highly  desirable,  if  possible,  to 
derive  a  number  based  on  actual  determinations  with  instruments, 
rather  than  to  take  an  arbitrary  number  as  the  standard  of  the  nor- 
mal hemoglobin  content.  This  of  course  means  that  in  order  to 
determine,  with  any  degree  of  accuracy,  what  is  the  normal  average 
hemoglobin  of  a  mixed  population,  nearly  all  of  whom  are  infected 
with  hookworm  disease,  it  is  necessary  first  to  separate  the  people  in- 
to sex  and  age  groups  and  determine  the  hemoglobins  of  these  groups. 

Therefore,  in  the  Commission's  investigation  of  the  subject  in  the 
Java  kampongs  that  were  free  from  malaria,  the  people  were  divided 
into  sex  and  age  groups.  A  group  from  a  kampong  highly  infected 
with  hookworm  disease,  and  presenting  cases  of  anemia,  was  com- 
pared with  a  corresponding  group  from  a  kampong  more  lightly 
infected.  It  was  observed  in  the  kampongs  where  there  was  much 
malaria  that  there  was  no  close  correspondence  between  the  degree 
of  anemia,  which  was  usually  severe,  and  the  number  of  worms  har- 
bored by  the  people.  On  the  other  hand,  in  kampongs  free  or  nearly 
free  from  evidence  of  malaria  a  high  positive  correlation  was  observed 
between  the  degree  of  anemia  and  the  number  of  worms.  It  should 
probably  be  added  that  while  this  was  true  of  averages  it  was  not 
necessarily  true  of  all  individual  cases.  A  standard  hemoglobin  for 
each  group  was  determined  from  the  data  obtained. 

The  problem,  as  presented  :n  Fig.  81  may  be  stated  as  follows: 
the  average  hemoglobin  of  the  boys  in  Kampong  Kalimaro  is  71.5  per 


KALIMARO 

BATAVIA 

Age  in  years 

9.7 

9.2 

Number  of  cases 

9. 

14. 

Normal  average  hemoglobin  of  boys 

85.0% 

85.0% 

Average  hemoglobin  of  boys  treated  in  the  kampongs 

71.5% 

82.3% 

Calculated  loss  due  to  hookworms 

13.5% 

2.7% 

Average  number  of  worms  harbored 

106.0 

20.7 

Calculated  number  of  worms  required  to  produce  a 
loss  of  1  per  cent  hemoglobin 

7.9 

7.7 

Loss  due  to  hookworms 

85.0-71.5=13.5% 

85.0-82.3=2.7% 

Number  of  worms  required  to  produce  1%  decrease 

~B%"7-9 

-^•-7.7 

Fig.  81. — Loss  of  hemoglobin  caused  by  hookworms  harbored.  Based 
on  examinations  of  23  boys  living  in  2  Java  kampongs 


88 


INTERNATIONAL   HEALTH    BOARD 


cent  and  their  average  worm  count  is  106.  The  average  hemoglobin 
of  boys  in  Kampong  Batavia  is  82.3  per  cent,  and  their  average  worm 
count  is  20.7.  What  should  be  the  hemoglobin  average  of  a  similar 
sex  and  age  group  whose  worm  count  is  zero?  There  were  sufficient 
data  for  working  this  out  for  men,  women,  and  boys.  The  standard 
for  men  was  worked  out,  first,  by  plotting  the  average  hemoglobin 
and  the  average  number  of  worms  obtained  from  the  men  of  Kali- 
maro;  next,  by  plotting  the  same  for  the  men  of  Kebasekan  (Fig.  82). 


HEMOGIOBII 

100 
90 
80 
70 
Kf\ 

i                                                                     « 

EMOGL08IN 

100 
90 

80 
70 
60 
50 
40 
30 
20 
10 
0 

94.8 

KEBA< 

EKAN 

^^ 

"^"^ 

KALIMAR 

Number  of  worms 
Hemoglobin 

^^ 

Memo; 

lobin   74-9^- 

^-"-•^ 

•"•"'^ 

62^^*-^^ 

50 

^  

Qrt 

20 
in 

0 

a 

)0               400               300               200                100                0 
NUMBER  OF  WORMS 

Fig.  82. — Method  of  determining  the  normal  average  hemoglobin 

A  line  from  the  first  through  the  second  intersected  the  line  of  no 
worms  at  the  point  represented  by  approximately  95.0  (i.  e.  94.8) 
per  cent  hemoglobin.  This  is  what  we  should  expect  to  find  as 
being  the  average  normal  hemoglobin  of  men  in  general.  Fig.  83, 
page  89,  presents  in  more  detail  the  data  regarding  men  in  two  Java 
kampongs. 

As  a  basis  for  discussion  we  shall  use  95.0  per  cent  as  the  average 
normal  hemoglobin  for  men,  ascertained  by  the  instrument  that  was 
used.  This  calculated  percentage  of  hemoglobin  (94.8  per  cent)  was 
rarely  or  never  found  among  the  kampong  men,  for  there  were  sev- 
eral causes  tending  to  lower  the  hemoglobin  content.  It  was  nearly 
approached,  however,  in  a  group  of  well-fed  men  in  the  Stadsver- 
band,  Batavia.  This  was  a  group  of  beriberics,  Chinese  and  Malays 


FINDINGS   CONCERNING    ANEMIA 


89 


KEBASEKAN 

KALIMARO 

Number  of  cases 

10. 

9. 

Calculated  normal  average  hemoglobin 

95.0% 

95.0% 

Average  hemoglobin  of  men  treated  in  the  kampongs 

74.9% 

62.8% 

Calculated  loss  due  to  hookworms 

20.1% 

32.2% 

Average  number  of  worms  harbored 

235.5 

378.4 

Calculated  number  of  worms  required  to  produce  a 
loss  of  1  per  cent  hemoglobin 

11.7 

11.8 

Loss  due  to  hookworms 

95.0-74.9=20.1% 

95.0-62.8»32.2% 

Number  of  worms  required  to  produce  1%  decrease 

235.5 
20.1       11'/ 

^f.1,.8 

Fig.  83. — Loss  of  hemoglobin  caused  by  hookworms  harbored.  Based 
on  examinations  of  19  men  living  in  2  Java  kampongs 

at  one  end  of  a  ward.  The  men  were  all  well  nourished,  but  on  ac- 
count of  physical  disability  were  unable  to  work.  They  were  living 
in  a  screened  ward,  free  from  malaria,  and  were  able  to  maintain  high 
hemoglobins.  The  range  of  hemoglobin  was  85  to  97  per  cent,  and 
the  average  for  the  group  of  9  men  was  92.3  per  cent. 

In  working  out  the  standard  for  the  women  a  marked  difficulty 
was  encountered.  The  cases  of  the  women  at  Kebasekan  exhibited 
a  very  definite  positive  correlation  between  the  amount  of  anemia 
and  the  number  of  worms,  as  is  seen  below: 


Percentage  of  hemoglobin 
Number  of  worms 


40,      46,      60, 
433,    261,    400, 


69,    84,    85,    86, 
31,    31,    38,    97, 


The  average  hemoglobin  was  69.7  per  cent,  and  the  average  number 
of  worms  was  163.3.  The  average  age  of  the  women  was  32.2  years, 
the  range  being  18,  18,  30,  32,  35,  40,  40,  50.  On  the  other  hand,  the 
women  of  Kalimaro  were  all  under  22  years,  the  average  being  20.5 
years,  and  the  range  18,  20,  20,  21,  21,  22,  22.  Of  the  seven,  4  were 
nursing  infants  at  the  time  and  the  2  with  the  lowest  hemoglobins 
were  pregnant.  It  had  already  been  found  that  the  pregnant  women 
might  have  hemoglobin  values  of  15  per  cent  less  than  the  non- 
pregnant  women  of  the  kampong.  It  was  preferred,  therefore,  not 
to  estimate  by  this  group  of  women  in  calculating  the  standard. 
Instead,  the  group  from  Kramat  and  Kebasekan  was  used. 

Kebasekan  Kramat         Calculated  for 


Number  of  cases  8 

Average  hemoglobin  69.7  85.6 

Average  worms  163.3  9.0 


86.5 
0.0 


The  standard  for  boys  was  derived  from  Kalimaro,  Kebasekan, 
and  Batavia. 

The  standard  85  per  cent  for  boys  will  be  used,  as  representing 
the  normal  average  hemoglobin  percentage  for  this  group. 

There  were  no  cases  of  anemia  among  the  girls,  and  no  marked 
differences  in  the  worm  counts  or  in  the  hemoglobin  values.     On  this 
account  we  shall  use  the  standard  derived  for  boys. 
6 


90  INTERNATIONAL   HEALTH    BOARD 

In  the  case  of  women  and  boys,  Kampong  Kramat  was  used  for 
comparison  with  Kebasekan  and  Kalimaro.  The  worm  counts  were 
very  low  in  Kramat,  and  the  loss  of  hemoglobin  may  have  been  com- 
pensated. In  that  case  85.6  per  cent  for  women  and  82.3  per  cent 
for  boys  should  be  used  as  a  standard.  In  the  case  of  men  the 
standard  is  derived  from  two  groups  having  definite  but  different 
amounts  of  measurable  anemia. 

Anemia  Caused  by  Hookworm  and  Malaria.  Malaria  is  very 
common  in  the  tropics.  Indeed,  malaria  and  hookworm  infection 
are  so  frequently  complicated  that  the  anemia  resulting  from  the 
one  has  often  been  attributed  to  the  activities  of  the  other.  On  the 
whole,  severe  anemia  due  to  hookworm  disease  is  less  common  than 
severe  anemia  due  to  malaria.  It  would,  of  course,  .be  very  desirable 
to  express  numerically  the  relative  importance  of  malaria  and  hook- 
worm infection  in  the  causation  of  anemia,  and  their  respective  places 
in  vital  statistics.  But  unfortunately  the  subject  is  so  complex  that 
it  is  not  possible  to  do  more  than  record  the  unanimous  conviction 
of  the  Commission  that  in  the  Federated  Malay  States  malaria  is 
the  more  serious  infection,  and  that  it  causes  far  more  anemia, 
debility,  and  death  than  hookworm  disease. 

In  the  Federated  Malay  States  so  much  malaria  was  found  that  it 
was  quite  hopeless  to  estimate  the  relative  importance  of  the  two 
infections,  especially  because  of  the  impossibility  of  entirely  elimi- 
nating, either  in  individuals  or  in  groups  of  cases,  recent  and  past  ma- 
larial influences.  In  Java,  on  the  other  hand,  while  there  were 
places  with  severe  malaria  and  little  hookworm  infection,  there  were 
other  places  with  severe  hookworm  infection  and  little  or  no  malaria. 
It  is  true  that  the  number  of  cases  in  the  series  studied  was  small,  but 
the  absence  of  malaria  was  so  nearly  complete  that  the  data  have 
been  used  in  an  attempt  to  ascertain  the  relative  values  of  the  two 
infections  in  Java — that  is,  in  places  where  the  malaria  is  as  severe 
as  it  is  in  many  places  in  the  Federated  Malay  States. 

The  data  obtained,  and  here  presented,  indicated  that  in  regions 
where  there  is  hookworm  infection  uncomplicated  by  malaria,  per- 
sons may  harbor  a  considerable  number  of  worms  without  showing 
any  measurable  degree  of  anemia.  In  the  same  community,  groups  of 
persons  were  sometimes  found  with  a  large  number  of  worms  and  a 
definitely  measurable  amount  of  anemia;  other  groups,  also,  were 
found  consisting  of  persons  with  anemia  of  a  more  severe  grade, 
and  with  a  still  larger  number  of  worms.  In  the  higher  grades  of 
hookworm  infection,  when  the  numbers  of  worms  mounted  into  the 
hundreds,  it  is  to  be  noted,  in  comparing  the  two  groups — whose 
respective  hemoglobins  differed  by  several  degrees — that  a  given 
number  of  worms  caused  a  certain  degree  of  anemia.  The  worms 
apparently  caused  a  loss  of  hemoglobin  at  such  a  rate  and  in  such  an 
amount  that  the  host  was  unable  to  counterbalance  the  loss,  and  the 
greater  the  number  of  worms  the  less  able  was  he  to  compensate  for 
losses.  Thus,  in  the  case  of  the  highest  worm  count  the  loss  of  a 


FINDINGS   CONCERNING   ANEMIA  9 1 

degree  of  hemoglobin  is  apparently  caused  by  fewer  worms  than  in 
the  case  of  the  medium  grades  of  worm  counts. 

If  losses  of  hemoglobin  are  going  on  in  the  cases  with  moderate  and 
high  worm  counts,  which  are  measurable,  it  may  be  safely  assumed 
that  in  lighter  and  lighter  cases  of  infection,  the  gradations  of  losses 
are  also  going  on,  correspondingly  lighter  and  lighter,  but  that  they 
are  counterbalanced,  so  far  as  we  are  able  to  measure  them. 

There  are  reasons  for  believing  that  in  places  like  Mid-Java,  about 
8  worms  in  a  boy  and  12  worms  in  a  man  may  cause  a  hemoglobin 
reduction  of  one  degree.  This  can  be  measured  in  places  where  the 
average  worm  counts  of  the  boys  are  over  100  and  the  average  worm 
counts  of  the  men  are  over  200.  Where  the  average  number  of  worms 
harbored  is  very  high,  the  worm  factor,  as  worked  out  here,  could  be 
applied.  Where  the  worm  counts  are  small,  the  cases  are  few  and  it 
is  not  possible  to  say  how  much  measurable  loss  is  suffered  by  the 
persons  with  a  few  worms.  This  is  due  to  the  fact  that  there  is  little 
or  no  resultant  anemia,  to  the  small  number  of  cases  in  the  series,  and 
to  the  normal  range  of  hemoglobin  in  persons  free  from  malaria  and 
hookworm  disease. 

The  effect  of  the  complement  of  worms  in  causing  anemia  is  coun- 
terbalanced when  the  reserve  powers  are  not  interfered  with.  But  if 
the  reserve  powers  are  weakened  and  broken  down  through  malaria, 
malnutrition,  under-feeding,  exhausting  labor,  and  other  causes,  the 
losses  of  blood  due  to  the  activities  of  the  hookworms  might  not 
altogether  be  made  up,  and  would  probably  cause  anemia.  It  would 
be  difficult  to  measure  the  amount  in  the  presence  of  another  cause, 
but  when  the  reserve  powers  are  entirely  broken  down — and  this 
apparently  is  what  happens  in  severe  cases  of  malarial  cachexia — one 
would  expect  hookworms  to  produce,  in  relation  to  number,  the 
same  amount  of  anemia  here  as  when  larger  numbers  are  harbored, 
causing  measurable  anemia. 

On  the  average,  a  moderate  number  of  worms,  say  250,  cause 
measurable  losses  of  hemoglobin,  and  it  is  reasonable  to  assume  that 
50  worms  would  cause  one-fifth  as  much,  whether  their  effect  was 
counterbalanced  or  not. 

Hookworm-Anemia  Factor.  In  the  presentation  of  this  sec- 
tion dealing  with  an  attempt  to  assign  a  definite  value  to  each  infec- 
tion as  a  cause  of  anemia,  the  expression  has  taken  a  numerical  form 
but  the  numbers  should  be  regarded  only  as  relative  and  approxi- 
mate, for  they  are  based  on  small  numbers  of  cases.  This  cannot  be 
emphasized  too  strongly.  Efforts  were  made  to  get  representative 
groups  of  the  population,  with  hemoglobin  determination  and  physi- 
cal examination  as  the  basis,  but  it  is  likely  that,  if  the  places  were 
re-visited,  while  essentially  the  same  results  would  be  obtained,  the 
factor  would  not  be  identical.  The  absence  of  the  complicating 
malaria  factor  is  nearly  complete  in  some  of  the  dessas,  so  that  the 
data  are  presented  with  the  reservation  that  the  figures  must  not  be 
taken  too  literally. 


INTERNATIONAL   HEALTH    BOARD 


The  worm-anemia  factor  is  based  purely  on  Java  findings.  In 
estimating  the  losses  of  hemoglobin  in  Penal  Institution  No.  3,  it  was 
observed  that  the  losses  due  to  hookworm  disease  were  markedly 
apparent  only  after  the  100-worm  group  had  been  passed.  In  the 
kampong  series  there  is  a  similar  fall  in  values  beyond  the  100-worm 
group,  but  there  is  also  a  progressive  fall  in  hemoglobin  values  from 
the  100-worm  group  to  the  0-worm  group.  In  view  of  the  positive 
correlation  of  worms  to  anemia  beyond  the  100-worm  group,  it  is 
difficult  to  account  for  the  apparent  discrepancy  in  the  group  with 

the  smaller  numbers  of  worms, 
unless  it  is  due  to  small  num- 
bers of  exceptional  cases.  There 
is  some  doubt,  therefore,  in  deal- 
ing with  the  series,  as  to  the 
effect  of  smaller  numbers  of 
worms  in  causing  anemia.  As 
a  matter  of  fact,  in  rural  districts 
it  was  unusual  to  find  a  small 
number  of  worms  in  persons  liv- 
ing under  conditions  in  which 
they  were  free  from  malaria. 
This,  however,  may  not  have 
been  due  to  any  influence  of 
malaria,  but  to  greater  liability 
of  acquiring  hookworm  infection 
in  the  latter  places,  as  atKebase- 
kan  and  Kalimaro.  (See  Table 
47,  page  171.) 

In  Sawah  Besar  and  Kramat 
there  was  little  or  no  evidence 
of  malaria  among  the  majority 
of  the  people,  and  here  the  pres- 
ence of  a  few  worms  was  corre- 
lated with  hemoglobin  values  a 
little  below  what  was  calculated 
for  the  normal,  the  indications  being  that  there  might  be  small 
losses  of  hemoglobin  and  slight  anemia  due  to  small  numbers  of 
worms.  The  number  of  cases  was  small,  however,  and  in  view  of  the 
range  in  hemoglobin  among  persons  free  from  malaria  or  hookworm 
disease,  and  the  effect  of  other  causes  of  anemia,  the  Commission  was 
led  to  believe  that  the  factor  may  be  of  use  only  when  the  number  of 
worms  is  large,  or  in  places  where  there  is  intense  malaria  and  when 
all  the  worms  are  probably  causing  anemia.  The  factor  is  also  an 
expression  of  the  number  of  worms  required  to  cause  a  unit  amount  of 
loss  of  hemoglobin  in  a  population,  irrespective  of  whether  it  repre- 
sents total  loss  or  loss  that  is  partly  or  fully  compensated.  Some  idea 
of  the  number  of  worms  required  to  cause  a  loss  of  1  per  cent  of 
hemoglobin  may  be  obtained  by  dividing  the  average  loss  of  hemo- 


NORMAL  HEMOGLOBIN  AVERAGE 
E2  ACTUAL  HEMOGLOBIN  AVERAGE 
9  LOSS  IN  HEMOGLOBIN  DUE  TO  HOOKWORM  DISEASE 

@  LOSS  m  HEMoeuHsm  DUE  TO  MALARIA 


Fig.  84. — Hookworm  infection 
and  malaria  as  anemia-producing 
factors  in  dessas  of  Gebongelir,  Java. 
By  sex  and  age  groups.  (Table  47) 


FINDINGS    CONCERNING   ANEMIA 


93 


globin  in  any  age  or  sex  group  into  the  average  number  of  worms 
actually  found  to  be  harbored  by  the  group.  This  method  is  illus- 
trated in  Figs.  81  and  83.  Here  it  is  seen  that  the  calculated 
number  of  worms  required  to  cause  a  loss  of  1  per  cent  hemoglobin 
in  a  boy  is  7  to  8,  while  in  a  man  it  is  11  to  12. 

By  means  of  these  factors  it  is  possible  to  calculate  the  amount 
of  anemia  caused  in  a  district  by  hookworm,  and  the  amount  of 
anemia  caused  by  malaria  can  also  be  estimated  by  difference.  This 
was  done  in  Gebongelir  after  a  representative  group  of  the  popula- 
tion had  been  examined,  treated,  and  their  expelled  worms  counted. 
(See  Table  47,  page  171.)  In  this  calculation  it  is  assumed  that 
only  two  causes  of  anemia  are  operative,  arid  it  is  estimated  that 
among  the  men  6.9  per  cent  of  their  anemia  is  due  to  hookworm 
and  32.0  per  cent  to  malaria. 

Hard  labor  and  sub-nutrition  are  undoubtedly  strong  factors  in 
accentuating  the  anemia  of  people  suffering  from  either  malaria  or 
hookworm.  An  attempt  to  estimate  the  effect  of  sub-nutrition  was 
made  among  prisoners  in  the  Batavia  jail,  Java.  (See  Table  49, 
page  173.) 

The  effect  of  hard  labor  on  prisoners  was  observed  in  Java,  and 
an  estimate  of  its  effect  on  the  hemoglobin  percentage  was  made. 
In  the  jail,  hookworm  treatment  was  administered  to  some  109  men, 
and  a  re-estimation  of  their 
hemoglobin  was  made  3  months 
later.  It  was  discouraging  to 
find  that  the  men  had  gained 
only  2.4  per  cent  hemoglobin  per 
man.  This  was  found  to  be  due 
to  the  combination  of  contin- 
uous malaria  re-infection  and 
hard  labor  on  a  prison  diet.  An 
estimatewas  made  of  the  amount 
of  anemia  caused  by  the  three 
chief  factors,  hard  labor,  malaria, 
and  hookworm  infection. 

Given  the  assumed  normal 
calculated  hemoglobin  of  men 
as  95,  the  loss  due  to  hard  labor, 
8.0,  or  the  difference  between 
85.3  and  77.3  (i.  e.  the  hemo- 
globin of  the  clerks  and  of  the 
prisoners  at  hard  labor)  is  sub- 
tracted, the  balance  being  87, 

which  should  include  the  losses  r.         oc 

,  Fig.     85. — Average     hemoglobin 

due    to    both     hookworm     and  rates  and  average  number  of  hook- 

malaria.  worms   harbored   in  one   malarious 

The    average    hemoglobin    of  and  two  non-malarious  dessas  of  Java, 

men  with  malaria  who  were  free  By  sex  and  age  groups.    (Table  48) 


^•AVERAGE  HEMOGLOBIN  (PERCENT) 

E23  HOOKWORMS  HARBORED  (AVERAGE  NUMBER) 


94 


INTERNATIONAL   HEALTH    BOARD 


from  hookworm  is 76.5;  this  subtracted  from87should  give  the  amount 
of  anemia  due  to  malaria,  or  10.5  per  cent.  The  average  hemoglobin  in 
each  worm  group  should  now  be  76.5  per  cent  if  there  were  no  hook- 
worm infection;  but  the  average  hemoglobin  of  each  group,  by  actual 
determination,  shows  marked  reduction  in  the  higher  worm  groups. 

The  amount  due  to  the  activities  of  the  worms  may  be  calculated 
by  subtracting  the  actual  averages  from  76.5,  leaving  a  balance  of  0 
in  the  "  0-worm"  group,  1.2  per  cent  in  the  "1  to  100"  worm  group, 
13.8  per  cent  in  the  "101  to  200"  worm  group,  9.1  per  cent  in  the 
"201  to  300"  worm  group,  26.5  per  cent  in  the  "301  to  400"  worm 
group,  and  39  per  cent  in  the  "401  and  over"  group. 
Or  if  the  109  treated  cases  are  taken,  it  is  assumed  that  their 

normal  hemoglobin  should  be 95  . 0% 

Deducting  the  average  hemoglobin  of  all  the  treated  groups.  .69.2 

Balance  =loss  due  to  various  causes 25 .  8% 

Deducting  the  loss  probably  due  to  hard  labor,  or  the  differ- 
ence between  the  average  hemoglobin  of  30  clerks  and  the 
average  hemoglobin  of  prisoners  at  hard  labor  (85.3  —  77.  3),  =8.0 


Balance 17 

The  average   number  of  worms  in  the  group  was  79.5;  when 
this  is  divided  by  the  factor  11.7  (see  Fig.  83)  the  amount 

of  anemia  due  to  hook- 
worm appears  to  be 
79.5^-11.7,  or 6. 


8% 


NORMAL  HEMOGLOBIN 
•  HEMOGLOBIN  LOSS  DUE  TO  HARD  LABOR  &  SUB-NUTRITION 
EJ  HEMOGIDBIN  LOSS  DUE  TO  MAURIA 
CDHEMOGLOBIN  LOSS  DUE  TO  HOOKWORM  DISEASE 


Fig.  86. — Respective  losses  in 
hemoglobin  from  hard  labor  and 
sub-nutrition,  malaria,  and  hook- 
worm infection.  Prisoners  in  Ba- 
tavia  jail,  Java.  (Table  49) 


Balance  =  the  loss  due  to 

malaria 11.0% 

The  effect  of  hard  labor  was 
estimated  by  comparing  the 
hemoglobin  of  30  clerks  at  light 
occupation  with  the  hemoglobin 
of  the  other  prisoners  who  were 
at  hard  labor.  The  diet  was 
exactly  the  same  in  quality  and 
quantity  for  each  class,  and  each 
was  infected  with  malaria  to  the 
same  extent.  The  hemoglobin 
of  the  clerks  was  8.0  per  cent 
higher  than  that  of  the  men  at 
hard  labor. 

The  loss  due  to  malaria  was 
estimated  by  taking  the  average 
hemoglobin  of  six  men  not  in- 
fected with  hookworm  and  using 
this  for  comparison  with  the 
others.  (See Table49, page  173.) 


FINDINGS    CONCERNING   ANEMIA  95 

In  some  of  the  dessas  of  Java  an  effort  was  made  to  determine 
the  percentage  of  that  loss  which  could  be  fairly  attributed  to  malaria, 
and  also  to  determine  the  percentage  which  could  be  reasonably 
attributed  to  hookworm  disease.  Results  in  a  given  malarious 
dessa  were  analyzed,  and  an  attempt  was  made  to  show  how  much 
anemia  was  due  to  malaria  and  how  much  was  due  to  hookworm 
infection. 

Gebongelir,  a  fishing  village  on  the  north  coast  of  Java,  presents  a 
striking  example  of  a  combination  of  hookworm  infection  and  malaria 
as  factors  in  producing  anemia.  (See  Table  47,  page  171.)  The  spleen 
rate  here  was  97  and  the  parasite  rate  was  29.  Instead  of  combining 
the  gross  average  hemoglobin  values  of  the  people  of  this  malarious 
dessa  with  those  of  another  dessa,  free  from  malaria,  it  seemed  best 
to  compare  the  hemoglobins  in  respective  age  and  sex  groups.  This 
comparison  showed  that  among  the  men  malaria  caused  about  five 
times  as  much  anemia  as  hookworm  infection;  among  the  boys  about 
three  and  one-half  times  as  much;  among  the  women,  and  perhaps 
among  the  girls,  about  fourteen  times  as  much. 

The  comparison  of  the  calculated  losses  due  to  malaria  in  Gebon- 
gelir with  the  calculated  losses  due  to  hookworm  infection  in  Kebase- 
kan  and  Kalimaro  (see  Table  47)  gives  one  a  fairly  good  idea  of 
the  damage  done  by  malaria  in  a  typical  dessa  in  the  densely 
populated  flatlands  of  Mid-Java.  The  calculated  normal  hemoglobin 
of  the  men  at  Gebongelir  was  95,  of  the  women  86,  of  the  boys  85, 
and  of  the  girls  85.  The  calculated  loss  due  to  malaria  in  this 
dessa  was,  among  the  men  32.0,  among  the  women  35.7,  among  the 
boys  22.1,  and  among  the  girls  15.5.  The  calculated  normal  hemo- 
globin in  the  dessas  Kebasekan  and  Kalimaro  was,  among  the  men 
95,  among  the  women  86,  among  the  boys  85,  and  among  the  girls  85 
— the  same  as  at  Gebongelir.  The  calculated  loss  due  to  hookworm 
disease  in  this  dessa  was,  among  the  men  25.8,  among  the  women 
16.3,  among  the  boys  13.5,  and  among  the  girls  2.0. 

Estimated  Loss  of  Hemoglobin  due  to  Hookworm  in  a 
Population  Subjected  to  Malaria.  An  estimate  of  the  quan- 
titative value  of  increasing  numbers  of  hookworms  in  causing  anemia 
was  also  made  by  analysing  the  large  number  of  cases  treated,  in  the 
Malay  States. 

This  series,  excluding  hospital  patients,  gave  a  total  of  818  cases. 
Of  these,  58  were  boys  and  girls  of  mixed  races,  though  mostly 
Eurasian,  found  in  the  Convent  School  at  Kuala  Lumpur;  75  were 
Malay  boys  found  in  the  schools;  and  92  were  Tamil  men,  women, 
and  children  who  worked  on  the  public  roads,  and  as  night-soil 
coolies;  63  were  Tamil  men,  women,  and  children  who  worked  as 
coolies  on  rubber  estates,  and  most  of  them  had  been  exposed  to 
malaria;  35  were  Tamil  men,  women,  and  children  detained  in  the 
quarantine  camp  at  Port  Swettenham;  58  were  Chinese  men,  women, 
and  children  detained  at  the  quarantine  camp  at  Singapore;  55  were 
Chinese,  Tamil,  and  Malay  men  at  Prison  No.  1;  and  352  were 


96 


INTERNATIONAL   HEALTH    BOARD 


Chinese,  Tamil,  and  Malay 
men  at  Prison  No.  2.  In  these 
several  groups  treated  and  ex- 
amined for  hookworm  disease, 
persons  of  both  sexes  and  of 
different  ages  were  included, 
and  all  varieties  of  physical 
condition  in  the  working  popu- 
lation were  represented.  The 
fact  that  the  cases  came  from 
schools,  rubber  estates,  public 
works,  quarantine  camps,  and 
prisons,  means  that  both  urban 
and  rural  populations  were 
represented. 

Tables  were  made  dividing 
the  whole  series  into  classes, 
according  to  the  numbers  of 
worms  expelled  by  treatment; 
and  the  average  hemoglobin 
of  each  class  was  calculated 
and  comparisons  made.  (See 
Table  50,  page  174.) 

The  hemoglobin  average  suf- 
fers no  drop  in  the  "1  to  5 
worms"  group  as  compared  with 
the  "0  worm"  group.  As  these 
two  groups  contain  a  large  num- 
ber of  cases,  the  average  ob- 
tained by  combining  them  will  furnish  a  good  standard  for  comparison 
with  the  other  groups.  Taking  the  average  hemoglobin  of  the  "0  to 
5  worms"  group,  the  difference  between  this  and  the  average  hemo- 
globin of  each  succeeding  worm  group  will  give  the  average  amount  of 
anemia  caused  by  the  corresponding  number  of  hookworms.  It  will 
be  seen  that  there  is  a  steady  loss  of  hemoglobin  with  an  increasing 
number  of  worms.  The  rate  of  loss  in  the  worm  groups  over  100 
is  higher  than  it  is  in  the  groups  lower  than  100.  This  is  probably 
due  to  the  host's  ability  to  make  good  the  losses  due  to  a  few  worms. 
The  smaller  number  of  worms  presumably  has  the  same  propor- 
tionate effect  in  causing  loss  of  blood  as  has  the  larger  number,  but 
the  effect  of  the  former  is  masked  and  not  readily  measurable.  In 
these  tables  a  loss  of  hemoglobin  is  understood  to  mean  the  measur- 
able or  evident  effect  of  the  infection,  and  does  not  include  any  loss 
which  can  be  compensated  for  by  blood  regeneration.  In  the  table 
based  on  analysis  of  all  the  cases,  the  average  loss  of  hemoglobin  is 
4.3  per  cent  per  case  and  the  average  number  of  worms  is  53.1. 
Therefore  the  ratio  of  the  loss  of  hemoglobin  to  the  number  of  worms 
is  1:12.3. 


Fig.  87. — Estimated  loss  of  hemo- 
globin due  to  hookworm  disease, 
among  populations  subjected  to 
malaria,  by  hookworm  groups;  818 
cases  treated  from  schools,  rubber 
estates,  public  works,  quarantine 
camps,  and  prisons  in  Federated 
Malay  States.  (Table  50) 


FINDINGS   CONCERNING   ANEMIA  99 

The  foregoing  cases  are  taken  irrespective  of  the  evidence  of  malaria. 
When  a  separate  analysis  of  the  cases  having  evidences  of  malaria 
(plasmodia  or  enlarged  spleen)  is  made,  it  is  seen  that  the  hemoglo- 
bins are  set  at  a  lower  level,  the  average  hemoglobin  of  the  "0-5 
worms"  group  being  74.5.  Among  prisoners  in  Java  it  was  76.5, 
instead  of  83.7  as  in  the  group  without  evidences  of  malaria.  This 
depression  of  the  average  hemoglobin  is  encountered  in  each  group 
and  is  due  to  the  effect  of  malaria.  The  difference  between  83.7  and 
74.5  (or  9.2)  is  due  to  malaria  and  may  be  compared  with  the 
amount  10.5  found  among  prisoners  in  Java.  In  155  cases  with 
evidences  of  malaria  the  average  loss  of  hemoglobin  is  5.9  per  case 
below  the  "0-5  worms"  standard  (74.5),  and  the  average  number  of 
worms  is  84.  Therefore  the  ratio  of  the  loss  of  hemoglobin  to  the 
number  of  worms  is  1:  14.2. 

In  663  cases  without  evidences  of  malaria  the  average  loss  of 
hemoglobin  is  3.2  per  case  below  the  "0-5  worms"  standard  (83.7). 
The  average  number  of  worms  is  45.8.  Therefore  the  ratio  of  the 
loss  of  hemoglobin  to  the  number  of  worms  is  1:  14.3. 

The  average  loss  due  to  hookworm  is  greater  in  the  malaria  cases, 
but  the  average  number  of  worms  is  greater  also.  The  fact  that 
the  ratio  of  loss  of  hemoglobin  to  the  numbers  of  worms  is  the  same 
in  the  malarial  and  non-malarial  groups  shows  that  the  worms  pres- 
ent exert  an  equal  influence  and  the  difference  in  loss  of  hemoglobin 
is  due  to  the  greater  number  of  worms  harbored  by  the  malaria 
cases.  This  indicates  that  a  given  number  of  worms  has  the  same 
effect  on  cases  with  malaria  as  it  does  on  cases  without  evidences  of 
malaria.  However,  in  the  groups  containing  a  larger  number  of 
worms  the  losses  due  to  hookworm  are  greater  in  the  cases  showing 
evidences  of  malaria. 

An  analysis  of  the  series  into  race,  age,  and  sex  groups  may  be 
made  in  the  same  way. 

In  361  Chinese  men,  women,  and  children  the  average  loss  of 
hemoglobin  is  1.4,  irrespective  of  evidences  of  malaria.  The  average 
number  of  hookworms  is  22.1.  Therefore  the  ratio  of  the  loss  of 
hemoglobin  to  the  number  of  worms  is  1:  15.8. 

In  172  Tamil  men,  women,  and  children  the  average  loss  of  hemo- 
globin in  the  group  is  5.3  per  case,  irrespective  of  evidences  of  mala- 
ria; the  average  number  of  worms  is  106.  Therefore  the  ratio  of  the 
loss  of  hemoglobin  to  the  number  of  worms  is  1:  20. 

The  Tamils  show  a  larger  loss  due  to  hookworm  than  the  Chinese, 
but  the  Chinese  have  a  lower  ratio  between  the  loss  of  hemoglobin  and 
the  number  of  worms.  This  means  that  fewer  worms  are  required 
to  produce  a  given  loss  of  hemoglobin  in  the  Chinese  than  in  the 
Tamils.  It  is  shown  elsewhere  that  Chinese  harbor  a  greater 
number  of  A.  duodenale  than  the  Tamils  do.  This  is  a  more  malig- 
nant worm  than  Necator  americanus,  and  causes  more  severe  anemia. 
Undoubtedly  the  differences  noted  above  are  due  to  the  large  pro- 
portion of  A .  duodenale  in  the  Chinese. 

In  459  men  the  average  loss  of  hemoglobin  is  1.7,  and  the  average 


IOO  INTERNATIONAL   HEALTH    BOARD 

number  of  worms  is  41.  Therefore  the  ratio  of  the  loss  of  hemoglo- 
bin to  the  number  of  worms  is  1:  24.4. 

In  44  women  the  average  loss  of  hemoglobin  is  9.9  per  case, 
and  the  average  number  of  hookworms  is  98.  Therefore  the  ratio 
of  the  loss  of  hemoglobin  to  the  number  of  worms  is  1 :  10. 

In  160  children  the  average  loss  of  hemoglobin  is  5.3,  and  the 
average  number  of  worms  is  44.5.  Therefore  the  ratio  of  the  loss 
of  hemoglobin  to  the  number  of  worms  is  1:  8.4. 

These  ratios  show  that  to  produce  a  given  loss  of  hemoglobin 
more  worms  are  required  in  a  man  than  in  a  woman,  and  more  in 
a  woman  than  in  a  child. 

From  this  method  of  analysis  the  conclusions  reached  are:  (1) 
that  in  a  population  the  loss  of  hemoglobin  due  to  hookworm  dis- 
ease may  be  measured,  within  certain  limitations,  by  comparing 
the  hemoglobins  of  cases  having  high  worm  counts  with  the  hemoglo- 
bins of  cases  with  low  worm  counts;  (2)  that  the  greatest  possible 
benefit  to  be  expected  from  treatment  may  be  estimated,  with  the 
same  limits  of  error,  in  any  hundred  cases  of  the  population;  (3) 
that  the  effect  of  a  given  number  of  worms  in  cases  with  evidence 
of  malaria  is,  on  the  whole,  the  same  as  that  in  cases  without  evi- 
dence of  malaria,  but  in  this  series  of  818  persons,  the  cases  with 
evidence  of  malaria  (i.  e.  plasmodia  and  splenic  enlargement)  showed 
a  greater  number  of  worms  and  a  correspondingly  greater  loss  of 
hemoglobin  than  the  cases  without  evidence  of  malaria  at  the  time  of 
examination;  (4)  that  fewer  worms  are  necessary  to  cause  a  given 
loss  of  hemoglobin  in  Chinese  than  in  Tamils,  and  that  this  is  prob- 
ably due  to  the  greater  percentage  of  the  more  malignant  Ancylos- 
tomes  in  the  Chinese;  (5)  that  fewer  worms  are  required  to  pro- 
duce the  same  loss  of  hemoglobin  in  children  than  in  women,  and 
fewer  in  women  than  in  men. 

Anemia  in  the  Fiji  Islands.  In  the  course  of  its  investigations 
in  the  Fiji  Islands  the  Commission  examined  a  group  of  Europeans 
consisting  of  41  men,  10  of  whom  had  been  born  in  Fiji,  the  rest 
having  resided  in  Fiji  from  5  years  and  under,  to  20  years  and  over. 
The  average  hemoglobin  of  these  men  was  88.8  per  cent,  which  was 
the  highest  of  any  group  examined  on  that  particular  island  where 
the  investigations  were  made  (Viti  Levu).  As  a  rule  they  were 
living  under  excellent  hygienic  conditions.  Upon  examination  of 
their  stools  it  was  found  that  Only  six  were  positive  for  hookworm 
disease,  and  even  among  these  the  number  of  worms  harbored  was 
apparently  too  small  to  influence  their  hemoglobin  unfavorably,  for 
their  hemoglobins  registered  85,  90,  91,  92,  94,  and  100  per  cent. 

Examination  was  made  of  18  of  the  European  women,  all  with 
the  same  length  of  residence  on  the  island.  Their  average  hemoglobin 
was  found  to  be  83.9  per  cent,  which  was  the  highest  average  found 
among  the  women.  They  were  all  free  from  hookworm  disease. 
The  average  hemoglobin  of  the  13  European  children  examined, 
between  4  and  15  years  of  age,  was  82.3  per  cent. 


FINDINGS    CONCERNING   ANEMIA  IOI 

Three  hundred  twenty-three  indentured  Indian  men  were  ex- 
amined. As  a  class,  they  were  found  to  stand  highest  among  the 
colored  population,  their  average  hemoglobin  being  noticeably  su- 
perior to  that  of  the  free  Indian  men,  either  town  dwellers  or  agricul- 
turists. Thirty  of  the  former  were  examined  and  139  of  the  latter. 
This  superiority  is  doubtless  due  to  the  better  hygienic  conditions 
under  which  the  indentured  Indian  lives,  and  to  the  medical  inspec- 
tion and  hospital  treatment  which  he  receives.  Sixty-four  Fijian 
boys  were  examined  at  the  Victoria  School,  their  ages  ranging  from 
9  to  17  years.  The  average  hemoglobin  for  the  group  was  but 
slightly  under  that  for  the  European  men,  i.  e.  88  per  cent.  As 
a  class,  these  boys  stood  very  high.  They  were,  for  the  most  part, 
sons  of  chiefs  and  came  from  vigorous  stock.  Their  nourishment 
had  always  been  carefully  provided  for  and  it  would  be  expected 
that  their  hemoglobins  would  be  higher  than  those  of  less  fortunate 
natives.  It  is  pertinent  to  mention  in  this  connection  that  in  the 
treatment  squad  of  Fijians  from  Nausori  village  there  were  two 
chiefs  and  their  hemoglobins  were  the  highest  in  the  squad. 

There  was  very  little  difference  between  the  hemoglobin  contents 
of  the  free  Indians  and  of  the  Fijians  who  lived  in  the  villages  near 
Nausori.  The  people  in  both  groups  were  well-fed,  comfortably 
housed,  and  not  overworked.  In  all  probability  they  were  not 
exposed  to  hookworm  infection  to  as  great  an  extent  as  the  free 
Indians  living  in  the  cane.  The  average  hemoglobin  of  the  Fijians 
stands  a  little  higher  than  that  of  the  Indians.  Here,  as  elsewhere, 
the  hemoglobin  values  of  women  were  found  to  be  influenced  con- 
siderably by  pregnancy.  Wherever  pregnancy  was  evident  at 
examination,  or  was  admitted  by  the  women,  the  case  was  not 
considered  in  the  tabulation  of  statistics.  In  fact  very  few  women 
were  included  in  the  treatment  squads,  because  there  are  reasons  for 
believing  that  the  statements  of  the  women  at  the  time  of  examination 
were  unreliable.  It  has  been  thought  best  to  base  comparisons  of 
worms  and  hemoglobins  exclusively  on  the  figures  for  men. 

Relation  of  Hookworm  Disease  to  Anemia  in  Fiji.  It  had 
been  hoped  it  would  be  possible  to  ascertain  with  some  exactitude 
the  effect  of  hookworm  infection  in  causing  anemia  in  a  population 
free  from  malaria,  but  in  order  to  do  this  it  would  have  been  neces- 
sary to  compare  the  hemoglobin  of  men  free  from  hookworms  with 
that  of  men  harboring  various  numbers  of  worms.  But  hookworm 
infection  was  found  to  be  so  nearly  universal  in  the  class  of  men  from 
which  it  was  desired  to  elicit  information  that  it  was  not  possible  to 
find  a  single  non-infected  man  to  furnish  a  basis  for  comparison. 

The  only  portion  of  the  adult  male  population  free  from  hookworm 
infection  was  European,  and  with  them  diet  and  occupation  would 
make  direct  comparison  unreliable,  for  the  reason  that  the  more 
liberal  diet,  the  lesser  exposure  to  sun  and  rain,  and  the  lighter  labor 
of  the  European  must  give  him  a  certain  advantage.  Attention 
should  be  called  to  the  high  hemoglobins  observed  in  the  well-fed 
but  bedridden  Chinese  beriberics  in  the  Batavia  Stadsverband,  and 


102  INTERNATIONAL   HEALTH    BOARD 

to  the  higher  hemoglobins  of  the  prisoner  clerks  in  the  Batavia  jail 
as  contrasted  with  their  fellow  prisoners  at  hard  labor. 

If  such  conditions  as  hard  labor,  jail  regimen,  insufficiency  of 
food,  and  the  like,  influence  nutrition  and  hemoglobin  values,  and 
if  these  conditions  vary  in  different  communities  under  varying 
circumstances  of  life,  it  would  seem  almost  impossible  to  make  any 
observations  which  would  be  strictly  comparable.  Attempts  to  com- 
pare Chinese,  Tamils,  Fijians,  and  Europeans,  therefore,  will  be  sub- 
ject to  error  resulting  from  differences  in  nutrition.  The  two  species 
of  hookworm,  Ancylostoma  duodenale  and  Necator  americanus,  it 
has  been  shown  (see  page  106,  section,  "Relation  between  Species  of 
Worms  and  Degree'of  Anemia"),  possess  different  degrees  of  malig- 
nancy. It  will  be  impossible,  therefore,  to  make  exact  comparisons 
based  on  total  worm  counts  where  the  proportion  of  the  two  species 
varies  very  much.  It  would  be  necessary  to  study  a  much  larger 
number  of  cases  than  the  Commission  was  able  to  study,  in  order  to 
minimize  discrepancies  due  to  individual  variations  in  hemoglobin. 
It  is  possible  only  to  give  the  results  secured  in  the  limited  time  at  the 
disposal  of  the  Commission  and  to  point  out  their  probable  indications. 

In  attempting  to  ascertain  the  degree  of  anemia  caused  by  different 
numbers  of  hookworms,  adult  Indian  males  have  been  taken  as 
representative  of  the  male  standard  of  hemoglobin.  Women  and 
children  follow  a  different  standard,  and  (the  former  especially) 
show  greater  individual  variations  in  hemoglobin.  Fijians  have 
been  excluded  from  consideration  because  of  the  uncertainty  as  to 
what  influence  racial  constitution,  diet,  and  mode  of  life  may  exert 
on  their  hemoglobins.  Besides,  their  numbers  are  small. 

Attention  has  already  been  called  to  the  low  hemoglobins  encoun- 
tered among  the  Indians  in  the  Suva  jail.  This  was  true  of  the 
entire  group  as  well  as  of  the  individuals  selected  from  the  treatment 
squads.  When  it  came  to  treating  the  men  it  was  found  that  the 
number  of  worms  obtained  was  insufficient  to  account  fully  for  the 
degree  of  anemia  observed.  Later,  examination  and  treatment  of 
the  indentured  Indians  at  Nausori  showed  their  hemoglobins  to  be 
uniformly  higher,  although  they  were  harboring  a  slightly  larger 
number  of  worms  than  the  Indians  in  the  jail.  Apparently  jail 
regimen  tended  to  lower  the  condition  of  nutrition  of  the  prisoners 
and  made  the  noted  differences  in  hemoglobin.  The  two  groups 
of  men  harboring  from  one  to  fifty  hookworms  may  be  directly 
compared. 

Number  Number  ,  ,  . 

,  ,  hemoglobin 

of  worms  of  cases  , 

of  group 

Jail  prisoners  1  to  50  19  76.3 

Indentured  coolies  1  to  50  31  85.8 

Here  it  is  seen  that  although  the  indentured  coolies  harbored  as 
many  hookworms  as  the  prisoners,  the  average  hemoglobin  of  the 


FINDINGS    CONCERNING   ANEMIA 


103 


former  was  9.5  points  higher.  This  would  seem  to  indicate  that, 
irrespective  of  their  hookworm  infection,  the  indentured  coolies  who 
are  regularly  employed  and  paid,  and  who  are  free  to  diet  themselves, 
do  keep  their  bodies  in  a  better  state  of  nutrition  and  exhibit  a 
higher  standard  of  hemoglobin  than  the  prisoners,  and  that  the 
superiority  of  the  former  is  due  mainly  to  better  diet. 

It  is  evident  that  if  it  is  desired  to  learn  the  measurable  loss  of 
hemoglobin  due  to  various  numbers  of  hookworms  we  must  note 
such  differences  as  are  encountered  among  two  such  groups  of  men 
as  we  have  just  referred  to — differences  in  the  hemoglobin  values 
which  we  must  attribute  to  something  other  than  difference  in  num- 
bers of  hookworms,  for  the  number  of  worms  (one  to  fifty)  is  the 
same  in  each  group.  Some  contributory  cause,  or  causes,  of  loss 
of  hemoglobin  must  be  present 
in  the  jail  group. 

Concerning  the  indentured 
coolies  as  a  class,  it  is  not  pos- 
sible to  say  what  the  average 
hemoglobin  of  a  non-infected 
portion  of  the  population  might 
be,  for  there  was  no  non-infected 
portion.  The  average  hemo- 
globin of  men  harboring  fewer 
than  lOworms  was  88.8  per  cent. 
If  we  consider  the  group  of  inden- 
tured men  who  harbored  from  1 
to  50  worms,  we  find  the  aver- 
age hemoglobin  of  the  31  cases 
to  be  85.8  per  cent.  Considering 
the  next  group,  or  those  men  with 
from  51  to  100  worms,  we  find 
that  the  average  hemoglobin  of 
the  16  cases  is  85.0  per  cent. 
It  may  therefore  be  assumed 
that  if  the  addition  of  50  worms 
depresses  the  hemoglobin  only 


NON-MALARIAl;IND£NTUREO  INDIAN  COOUES-FIJI. 
SEVERELY  MALAQIALJAVANESE  MEN  IN  BATAVIA  JAIL 


Fig.  90. — Diminished  hemoglobin 
from  prolonged  malaria  infection 
superimposed  upon  hookworm  in- 
fection. Note:  Heavy  horizontal  line 
indicates  hemoglobin  loss  due  partly 
to  malaria  and  partly  to  jail  regi- 
men. (Table  51) 


0.8    per   cent,    the    hemoglobin 

of   men    free   from   hookworms 

should    not    be   far    from    86.0 

percent.     One  hundred  worms, 

or  fewer,  do  not  seem  to  cause 

any  measurable  loss  in  hemoglobin.     In  the  next  group,  the  coolies 

have  from  101  to  150  worms;  the  average  hemoglobin  of  the  9  men 

is  81.8  per  cent.     Here,  apparently,  the  load  seems  to  be  too  heavy 

to  be  borne  without  measurable  loss  in  hemoglobin. 

Attention  has  been  called  to  the  difference  between  the  hemoglobin 
of  the  indentured  coolies,  and  that  of  the  prisoners  in  the  jail  who 
were  living  under  a  different  regimen.  The  effect  of  prolonged  mala- 


104 


INTERNATIONAL   HEALTH    BOARD 


ria  infection  superimposed  upon  men  already  infected  with  hook- 
worm disease  may  be  seen  by  comparing  the  indentured  Indian 
coolies  with  a  group  of  Javanese  from  three  kampongs  and  from  the 
Batavia  Jail,  who  were  heavily  infected  with  malaria.  The  data 
are  exhibited  in  Table  51,  page  175. 

Here  the  hemoglobins  of  a  group  of  indentured  Indians  who  were 
not  heavily  infected  with  hookworm  disease,  and  who  were  not  suf- 
fering noticeably  from  anemia,  are  compared  with  those  of  Javanese 
of  similar  classes  who  were  suffering  severely  from  malaria  and  who 
were  at  hard  labor.  The  Indians  were  in  good  physical  condition 
and  were  engaged  in  agricultural  pursuits.  Their  hemoglobins  were 
fairly  high,  but  we  have  no  doubt  that  if  it  had  been  possible  to  take 
them  from  the  fields  and  put  them  on  a  regimen  of  very  light 
exercise  with  a  rich  diet,  their  hemoglobins  on  the  average  could 

have  been  raised 
four  or  five  points 
higher  in  spite  of 
their  hookworm 
infection. 

Considering  the 
scarcity  of  labor, 
the  approach  of 
the  cane-crushing 
season,  and  the 
time  limitations, 
it  would  have 
been  impossible 
to  carry  out  such 
an  experiment, 
and  the  strong 
probability  of 
such  factors  as 
diet  and  hard 
labor  influencing 
the  hemoglobin 


100!  -1050 

rr 

RMS  HARBORED 

90  -950 
85  -900 

75  -800 

~ 

1  —  !- 

70  -750 

60  -650 
55  -600 

~ 

— 

• 

JMBER  OF  WC 

45  -500 
40  -450 
35  -400 
30  -350 
25  -JOO 
20  -250 

~ 

I 

•^ 

• 

• 

• 

• 

z 

15  -ZOO 
10  -150 
31-100 
0-50l 

o 

8 

i$ 

CO 

r 

I 

H 

:M 

OG 

a 

LO 

Bl 

>( 

Sf 
U 

rE 

s 

i 

8 

5 

0    w> 

Fig.  91. — Correlation  between  number  of  hook- 
worms harbored  and  rate  of  hemoglobin;  131  Indians 
free  of  malaria  but  infected  with  hookworm  disease 
at  Nausori  and  in  Suva  jail.  Fiji  Islands.  Each 
dot  indicates  one  person.  (Table  52) 


content  can  be  assumed  only  from  the  observations  on  the  night- 
soil  coolies  of  Kuala  Lumpur,  on  bedridden  Chinese  beriberics  in 
the  Batavia  Gefangenis,  and  on  the  prisoners  at  Batavia  and  Suva. 
In  the  Hospital  ward  at  Kuala  Lumpur,  observations  on  the  slow 
convalescence  from  severe  malarial  anemia  of  some  of  the  vegeta- 
rian rice-eating  Tamil  patients,  when  compared  with  the  more  rapid 
recovery  of  the  meat-eating  Chinese,  suffering  from  anemia  of  simi- 
lar cause,  undoubtedly  have  a  bearing  on  this  question. 

With  the  possible  exception  of  the  Fijians,  the  group  of  men  har- 
boring from  1  to  150  worms,  and  having  the  highest  average  hemo- 
globins, is  represented  by  the  indentured  coolies.  The  indications 
are  that  the  Fijians  would  stand  as  high  or  higher,  but  the  number 
of  treated  cases  is  too  small  to  offer  precise  information  on  this  point. 


FINDINGS   CONCERNING   ANEMIA 


105 


90 


80 


70 


60 


r 

DO    50 
O 


30 


20 


10 


7S.7 


793 


65.0 


640 


50.0 


35.0 


35.0 


55.0 


I 


15.0 


40.0 


55JO 


5.0 


NUMBER  OF  HOOKWORM5  HARBORED 


Fig.  92. — Correlation   between  number  of  hookworms  harbored  and 
rate  of  hemoglobin.     Based  on  Fig.  91.     (Table  52) 


106  INTERNATIONAL   HEALTH    BOARD 

The  Fijian  treatment  squad  contained  two  well-nourished  chiefs,  and 
the  hemoglobins  of  the  treatment  squad  were  higher  than  those  of 
the  population  from  which  most  of  the  men  came.  These  facts  are 
brought  out  in  correlation  Table  52,  page  176. 

The  131  cases  included  in  this  correlation  table  were  all  Indian 
men.  They  included  Nausori  Indians,  both  indentured  and  free, 
and  a  small  number  from  Suva  jail.  All  were  infected  with  hook- 
worm disease  to  a  greater  or  less  extent. 

On  account  of  the  comparatively  small  numbers  in  the  different 
worm  and  hemoglobin  groups,  and  the  inclusion  of  prisoners  who 
were  underfed,  deductions  must  be  made  with  caution.  However, 
certain  generalizations  are  possible.  Judging  by  the  disposition  of 
the  cases  in  the  body  of  the  table,  no  marked  positive  correlation 
of  number  of  worms  to  measurable  loss  in  hemoglobin  will  be  seen 
until  the  251-300  group  is  reached.  If  the  cases  with  250  worms  or 
fewer  are  counted,  it  is  seen  that  nearly  80  per  cent  of  the  whole  group 
of  131  show  little  measurable  loss  of  hemoglobin  attributable  to  the 
worms  found  at  treatment.  Where  the  worm  content  is  251  or  over, 
the  loss  of  hemoglobin,  as  worms  increase,  is  striking.  As  several  cases 
of  severe  anemia  were  included,  the  proportion  of  low  hemoglobins  in 
the  treated  squads  exceeds  that  found  in  the  population  as  a  whole, 
and  the  table  gives  the  impression  of  a  greater  amount  of  hookworm 
anemia  than  was  probably  present  in  the  community. 

The  hemoglobin  averages  printed  at  the  left  of  the  table  show  great 
oscillation,  as  might  be  expected  of  averages  of  relatively  small 
numbers  of  highly  variable  units.  There  is  no  striking  reduction  in 
average  hemoglobin  until  the  301-350  group  is  reached,  since  the 
average  of  the  251-300  group  (79.3  per  cent)  is  but  little  below  that 
of  the  0-50  group  (82.5  per  cent).  When  the  worm  content  is  301 
or  over,  a  marked  reduction  in  average  hemoglobin  is  noticeable. 
The  average  hemoglobins  of  all  worm  classes  below  this  point  run 
from  10  to  50  per  cent  below  the  lowest  of  any  superior  class,  i.  e., 
any  class  with  300  worms  or  fewer.  When  the  hemoglobin  regis- 
tered above  85  per  cent,  there  was  little  tendency  toward  decrease, 
even  though  hookworm  infection  was  present.  On  the  whole,  the 
hemoglobins  of  this  malaria-free  group  apparently  kept  up  in  the 
presence  of  a  comparatively  high  number  of  worms.  Beyond  a  cer- 
tain worm  count  the  hemoglobins  fell  rapidly. 

Relation  Between  Species  of  Worms  and  Degree  of  Anemia. 

It  was  observed  by  the  Commission  that  in  cases  of  infection  the 
same  number  of  worms  caused  a  greater  degree  of  anemia  among 
Chinese  than  among  Tamils.  As  Chinese  harbor  much  larger 
numbers  of  A.  duodenale  than  Indians  do,  the  fact  was  taken  to 
indicate  that  Ancylostomes  are  more  malignant  than  Necators. 

Two  Chinese  suffering  from  severe  anemia  were  studied.  Their 
faces  were  of  a  peculiar,  waxy  pallor,  but  there  was  no  edema;  mala- 
ria plasmodia  were  absent  on  admission,  and  their  spleens  were  not 
palpable.  Inasmuch,  therefore,  as  malaria  as  a  cause  of  anemia  was 


Fig.  93. — Tamil  and  Chinese  with  severe  anemia  and  waxy 
pallor.     No    improvement   after   treatment.     The  blood- 
forming  organs  had  become  exhausted 


FINDINGS   CONCERNING  ANEMIA  1 09 

absent,  it  was  presumed  from  their  appearance  that  they  must  have 
been  harboring  large  numbers  of  hookworms.  (See  Fig.  93.)  As  a 
matter  of  fact,  on  treatment  they  yielded  only  302  and  265  worms 
respectively.  This  fact  naturally  led  to  the  inference  that  Ancylos- 
tomes,  by  giving  rise  to  greater  hemorrhage,  might  be  the  cause  of  a 
more  severe  grade  of  anemia  than  Necators. 

This  inference  was  more  or  less  confirmed  by  a  post-mortem 
examination  of  a  Chinese  who  harbored  1,203  A.  duodenale  and  116 
N.  americanus,  and  in  whom  there  was  profuse  hemorrhage  directly 
due  to  worm  bites.  The  hookworms  that  were  recovered  were 
bathed  and  imbedded  in  pale,  bloody  mucus.  Numerous  worm 
bites  were  seen,  surrounded  by  circular  areas  of  hemorrhage,  but 
such  worm  bites  were  not  nearly  so  numerous  as  the  number  of 
attached  worms.  It  is  therefore  evident  that  hemorrhage  does  not 
occur  from  every  worm  bite.  Practically  all  of  the  hookworms 
found  were  in  the  jejunum;  none  were  in  the  ileum.  It  was  not 
uncommon  in  treatment  cases  to  find  A.  duodenale  with  bloody 
intestinal  tracts;  in  fact,  two  of  the  three  cases  with  lowest  hemo- 
globins, treated  in  Penal  Institution  No.  3,  showed  bloody  worms  in 
the  first  washings  after  treatment.  It  was  observed  that  among 
cases  of  infected  Chinese  on  the  one  hand,  with  their  large  number 
of  Ancylostomes,  and  among  Tamils  on  the  other  hand,  with  their 
nearly  purely  Necator  formula,  equal  numbers  of  worms  did  not 
cause  anemia  of  equal  severity.  It  was  thought  possible  that  the 
A.  duodenale — with  its  larger  and  more  strongly  armed  chitinous 
mouth-parts — might  cause  more  hemorrhage  and  more  anemia  than 
the  smaller,  weaker-mouthed  Necator. 

A  series  of  experiments  was  conducted  and  the  results  of  the 
experiments  were  tabulated.  Out  of  a  total  of  90  cases  of  Chinese, 
there  were  16  that  harbored  40  or  more  Ancylostomes — in  addition 
to  the  Necators  present.  Five  harbored  from  46  to  129,  and  6  from 
85  to  265,  while  5  harbored  from  253  to  1,203.  A  clinical  examina- 
tion showed  that  several  of  the  patients  were  suffering  from  severe 
anemia.  There  were  four  deaths. 

Out  of  a  group  of  16  Tamils  examined  in  this  connection,  there 
were  only  two  cases  of  uncomplicated  hookworm  anemia.  The 
first  of  these  harbored  no  Ancylostomes  and  710  Necators,  and  the 
second  harbored  2  Ancylostomes  and  1,061  Necators;  both  were 
anemic  and  had  more  or  less  edema,  but  neither  was  broken  down. 
Of  the  16  Tamils,  14,  or  87.5  per  cent,  showed  evidence  of  malaria, 
but  in  spite  of  this  malaria  and  the  number  of  hookworms  harbored 
(mostly  Necators)  there  were  no  deaths.  In  fact,  in  the  group  of 
16  Chinese  examined,  only  8,  or  50  per  cent,  gave  evidence  of  malaria, 
although  as  a  matter  of  fact  the  anemia  present  was  very  severe  and 
5  out  of  the  16,  or  31.2  per  cent,  died.  These  facts  are  significant 
and  indicate  that  Ancylostoma  duodenale  is  probably  a  more  powerful 
agent  in  the  causation  of  anemia  than  Necator  americanus. 

Another  type  of  patient  was  found  (a  Tamil  who  had  been  a  va- 
grant for  one  and  one-half  years)  who  had  both  malaria  and  hook- 


IIO  INTERNATIONAL   HEALTH    BOARD 

worm  disease,  and  in  whom  edema,  ascites,  and  diarrhea  were  evi- 
dent. Although  550  hookworms  were  removed — 32.3  per  cent  being 
A.  duodenale  probably  derived  from  Chinese  sources — his  condition, 
far  from  improving,  actually  grew  worse.  For  five  weeks  after 
admission  there  was  no  change  in  the  condition  of  slight  edema  and 
ascites.  After  the  sixth  week,  the  edema  of  the  legs  increased  rapidly 
and  this  condition  lasted  for  five  weeks,  after  which  the  edematous 
condition  diminished  for  two  weeks,  only  to  return  subsequently  for 
another  period  of  two  weeks.  During  the  third  week  diarrhea  made 
its  appearance  and  was  severest  two  weeks  before  the  time  when 
the  edema  was  mildest,  and  all  through  the  period  of  severe  edema 
the  diarrhea  was  equally  severe.  The  severity  of  this  case  was  due 
in  part  to  the  large  number  of  A.  duodenale. 

Severe  Malaria  (Gachezia)  Mistaken  for  Hookworm  Disease. 

In  the  hospital,  study  was  made  of  a  series  of  cases  which  included 
men  free  from  hookworm  but  suffering  from  severe  malarial  anemia, 
with  edema  and  debility.  The  importance  of  this  particular  series 
lies  in  the  fact  that  while  the  wretched  physical  condition  of  the 
men  was  found  to  be  entirely  due  to  malaria,  the  patients  were  of  the 
type  whose  symptoms  are  usually  diagnosed  by  practitioners  and 
intelligent  laymen  as  cases  of  ancylostomiasis  or  uncinariasis.  The 
malaria  factor  is  almost  always  entirely  overlooked.  A  typical 
case,  with  conclusive  evidence  that  the  condition  found  was  due  to 
malaria  and  not  to  hookworm,  was  that  of  Murugan,  a  Tamil  dhoby. 
In  July,  1915,  this  case  was  treated  for  malaria  in  the  hospital  ward. 
He  was  admitted  on  July  6,  with  malaria  and  hookworm  disease. 

On  July  8,  the  examination  of  feces  for  hookworm  ova  revealed  the 
fact  that  a  few  were  harbored.  Examination  of  blood  on  July  8, 
10,  12,  14,  16,  19,  21,  23,  26,  and  28  showed  crescents.  Examinations 
on  August  2  and  3  showed  the  blood  to  be  negative  for  plasmodia. 
The  examination  on  August  4  again  revealed  crescents.  Examina- 
tion on  August  6,  9,  and  11  showed  the  blood  to  be  negative  for  plas- 
modia, and  the  examination  on  August  12  showed  subtertian  rings. 
From  July  8  to  19  the  patient  received  quinine  treatment.  On 
August  4  chenopodium  treatment  was  administered  and  39  hook- 
worms were  recovered.  On  seven  subsequent  examinations  (August  9, 
10,  11,  12,  13,  14,  and  17)  his  stool  remained  negative  for  ova.  On 
August  9  he  had  a  paroxysm  of  malaria  and  his  temperature  remained 
remittent  for  four  days.  On  the  fourth  day  plasmodia  were  again 
found.  A  slight  edema  of  the  feet,  noticed  upon  admission,  disap- 
peared rapidly.  Before  the  paroxysm  of  malaria  occurred,  his  hemo- 
globin had  risen  from  28  to  67.  Five  days  after  this  his  temperature 
reached  normal,  when  there  was  no  edema — then  he  left  the  hospital 
abruptly. 

Twenty-seven  days  later  he  returned,  after  spending  the  larger 
part  of  the  interval  at  Kajang,  twenty  miles  away.  For  three  days 
he  worked  as  a  dhoby  in  Kuala  Lumpur.  His  fever  returned  and 
he  took  quinine.  Unable  to  work,  he  was  cared  for  by  his  friends. 


FINDINGS   CONCERNING   ANEMIA  III 

His  face  and  legs  began  to  swell  and  he  returned  to  the  hospital, 
presenting  a  wretched  appearance.  Investigation  showed  that  he 
had  severe  anemia,  that  his  face  was  puffy,  and  that  there  was  slight 
edema  of  legs  and  feet  as  well  as  some  emaciation.  The  condition 
which  he  presented  is  frequently  miscalled  ancylostomiasis;  but  as 
a  matter  of  fact  his  stools  were  found  to  be  negative  for  hookworm 
ova  on  seven  examinations.  On  the  other  hand,  his  spleen  was 
greatly  enlarged,  below  the  umbilicus,  and  plasmodia  were  found 
in  his  blood — subtertian  and  B.  tertian  rings. 

It  will  be  recalled  that,  when  he  left,  his  hemoglobin  registered  67 
per  cent.  Upon  his  return  it  was  found  that  it  had  dropped  to  12 
per  cent,  while  the  erythrocytes  had  fallen  from  66.3  per  cent  to 
18.8  per  cent.  He  responded  to  treatment  and  made  a  fairly  rapid 
recovery,  his  hemoglobin  rising  to  68  per  cent  in  35  days,  or  an 
average  of  1.6  per  cent  per  day.  The  Commission  found  many 
similar  cases.  Investigation  revealed  a  number  of  cases  of  Tamils 
or  Malabaris  who  had  severe  anemia,  edema,  and  debility,  but  who 
harbored  only  small  numbers  of  hookworms.  On  account  of  the 
similarity  of  these  cases  to  the  foregoing,  the  cause  of  the  symp- 
toms was  attributed  to  malaria  rather  than  to  hookworm. 

Rate  of  Blood  Regeneration  in  Hookworm  Disease  and  in 
Malaria.  As  has  already  been  pointed  out,  a  special  ward  at  the 
hospital  at  Kuala  Lumpur  was  assigned  to  the  Commission  for  its 
use.  One  of  the  problems  which  the  Commission  undertook  to 
solve  was  whether  or  not  hookworm  infection  retarded  blood  regen- 
eration in  malaria,  and,  if  so,  to  what  extent. 

Chinese  and  Tamil  coolies  who  were  in  a  badly  broken-down 
condition  were  admitted  to  the  hospital.  In  some  of  these  cases 
severe  and  extreme  anemia  was  detected.  When  the  examinations 
of  feces  and  blood  were  being  made  of  the  332  patients  who  were 
admitted  into  the  ward,  hemoglobin  determinations  were  carried 
out  on  them  at  the  same  time.  An  analysis  of  the  results  disclosed 
a  very  striking  difference  between  the  hemoglobin  contents  of  the 
Chinese  and  of  the  Tamils,  when  the  findings  (with  reference  to  the 
presence  or  absence  of  malaria  and  hookworm  disease)  were  compared. 

These  examined  cases  fell  into  four  groups:  (1)  those  who  had 
neither  hookworm  disease  nor  malaria;  (2)  those  who  had  hookworm 
disease  only;  (3)  those  who  had  malaria  only;  and  (4)  those  who 
had  both  malaria  and  hookworm  disease. 

The  classification  "malaria  only"  merely  implies  the  presence  of 
plasmodia  in  the  peripheral  blood  at  the  time,  as  detected  in  the 
thick  film.  Absence  of  hookworm  disease  may  be  taken  to  mean 
absolute  absence,  as  well  as,  in  some  cases,  such  sparseness  of  ova  in 
thne  specimen  that  they  were  not  detected.  Inasmuch  as  this 
usually  means  that  few  worms  are  present,  it  indicates  that  the 
anemia  found  was  not  due  to  the  presence  of  any  large  number  of 
worms.  Absence  of  malaria  does  not  necessarily  indicate  what  may 
have  taken  place  in  the  peripheral  blood  or  in  the  viscera  before 


112  INTERNATIONAL  HEALTH   BOARD 

entrance  to  the  hospital.  As  a  matter  of  fact,  the  average  hemo- 
globin of  these  cases  showed  that  there  had  been  a  very  severe  loss 
of  hemoglobin  due  to  causes  other  than  hookworm  infection,  but 
principally  to  malaria. 

Classification  "neither  hookworm  disease  nor  malaria"  means 
that  there  might  have  been  very  few  hookworms  present,  and  that 
the  degree  of  anemia  indicated  was  the  result  of  a  recent  attack  of 
malaria,  although  plasmodia  had  disappeared  from  the  blood  stream 
at  the  time  of  examination.  In  each  class  the  Chinese  showed  a 
decided  superiority  to  the  Tamils,  so  far  as  the  average  hemoglobin 
was  concerned. 

It  will  be  seen  by  reference  to  the  summary  below  that  when  the 
plasmodia  or  ova  are  demonstrable,  the  amount  of  anemia  due  to 
malaria  is  greater  than  the  amount  due  to  hookworm  disease,  there 
being  about  twice  as  much  among  the  Chinese  and  about  three  times 
as  much  among  the  Tamils.  Furthermore,  it  will  be  observed  that 
the  amount  of  anemia  among  the  Tamils,  due  to  hookworm  disease, 
was  found  to  be  about  twice  as  great  as  among  the  Chinese,  while  the 
amount  of  malaria  was  found  to  be  about  two  and  one-half  times 
as  great. 

Percentage  Hemoglobin 

Chinese  Tamils 

Neither  infection  48.8%  42.2% 

With  hookworm  disease  only  46.9%  38.7% 

Loss  due  to  hookworm  disease  1.9%  3.5% 

Neither  infection  48.8%  42.2% 

With  malaria  only  44 . 9%  31. 7% 

Loss  due  to  malaria  3.9%  10.5% 

It  must  be  remembered,  in  noting  these  differences  between  the 
Chinese  and  Tamils,  that  to  a  certain  extent  they  follow  different 
occupations.  The  Tamils,  for  the  most  part,  are  employed  on 
rubber  estates  and  on  public  works,  while  the  Chinese  for  the  most 
part  work  in  tin  mines,  or  as  vegetable  gardeners,  artisans,  and  shop- 
keepers. Thus,  the  races  are  exposed  in  varying  degrees  to  malaria. 
The  religious  and  caste  restrictions  of  Tamils  prevent  them  from 
eating  beef  or  pork,  requiring  them  to  be  to  a  considerable  extent 
vegetarians.  On  the  other  hand,  the  Chinese  have  no  such  dietary 
restrictions  and  eat  heartily.  These  differences  between  the  races 
undoubtedly  affect  their  liability  to  infection,  and  also  their  abil- 
ity to  recuperate  afterward.  Behind  such  influences  as  occupation 
and  environment  as  related  to  the  amount  of  illness  of  the  respective 
races,  there  appears  to  be  something  deeper  and  more  of  the  character 
of  ethnic  vitality,  temperament,  or  metabolism. 

During  physical  examination  the  reflex  activities  of  the  Chinese 
are  at  once  noticeable,  as  is  shown  in  the  difficulty  experienced  by 


FINDINGS   CONCERNING  ANEMIA 


the  examiner  in  taking  their  spleen  rates.  While  the  Tamils  have 
a  soft,  flaccid  belly-wall,  usually  free  from  rigidity,  the  abdominal 
wall  of  the  Chinese  almost  jumps  to  meet  the  hands  of  the  examiner. 
This  rigidity  is  more  or  less  a  rule  among  the  Chinese  men,  and  inter- 
feres not  a  little  with  the  rapidity  or  accuracy  with  which  their 
spleen  rates  can  be  taken.  This  reflex  nervous  irritability  is  an 
index  of  something  far  more  commonly  seen  in  Chinese  than  in  other 
races.  There  are  other  indications,  also,  that  the  Chinese  as  a  race 
are  more  vigorous  and  resistant  to  disease  than  are  the  Tamils:  for 
example,  the  comparative  rapidity  with  which  they  convalesce  from 

debilitating  disease  and  the  ex- 
traordinary way  their  tissues 
react  to  the  virus  of  syphilis. 

Table  53,  page  177,  with  refer- 
ence to  the  time  required  to  raise 
the  hemoglobin  in  anemic  pa- 
tients, shows  that  a  very  disap- 
pointing feature  of  the  hospital 
work  was  the  inability  to  raise 
the  hemoglobin  value  up  to  nor- 
mal after  the  patients  had  recov- 
ered from  an  attack  of  malaria, 
and  after  they  had  been  treated 
and  freed  from  their  hookworms. 
Very  often  their  general  appear- 
ance would  be  good  and  their 
weight  would  have  so  increased 
that  they  would  ask  for  their  dis- 
charge, when  as  a  matter  of 
fact  their  hemoglobin  registered 
only  from  30  to  60  per  cent.  It 
was  observed  that  the  lower  a 
man's  hemoglobin  was  on  ad- 
mission, the  greater  was  the 
difficulty  in  getting  it  up  to 
60  or  70  per  cent.  It  was  also 
observed  that  when  it  registered 


Fig.  96. — Time  required  to  raise 
hemoglobin  rates  of  anemic  patients, 
following  treatments  for  malaria  and 
hookworm  disease.  Fifty-eight  cases 
treated  in  special  ward  at  Kuala 
Lumpur  hospital.  (Table  53) 


10  per  cent  or  less  it  was  usually  impossible  to  raise  it  to  70  per  cent 
within  three  months. 

The  Commission  was  particularly  anxious  to  ascertain  whether 
hookworm  infection  retarded  blood  regeneration  in  malaria,  and,  if  so, 
to  what  extent.  In  order  to  discover  these  facts  it  was  necessary, 
(1)  to  determine  the  rate  of  blood  regeneration  in  cases  of  pure 
hookworm  infection;  (2)  to  determine  the  rate  of  blood  regeneration 
in  cases  of  uncomplicated  malaria,  if  such  cases  could  be  found; 
(3)  to  ascertain,  if  possible,  what  effect  one  infection  had  on  the  other 
— whether  each  advanced  as  though  the  other  were  absent,  or  whether 
there  was  any  accentuation  of  either  infection;  and  (4)  to  note 


114  INTERNATIONAL  HEALTH   BOARD 

whether  hookworm  infection  retarded  convalescence  from  malaria, 
and  whether  relapse  of  malaria  might  not  mask  the  benefit  of  hook- 
worm treatment.  It  is  true  that  the  hospital  yielded  abundant  mate- 
rial for  investigation  along  these  lines,  but  it  is  also  true  that  a  dis- 
advantage was  experienced  because  of  the  fact  that  the  patients 
frequently  absconded  from  the  ward  during  treatment  (29.5  percent 
of  the  332),  thus  making  it  necessary  to  abandon  many  experiments 
altogether,  or  else  begin  them  all  over  again.  A  number  of  important 
experiments  were  ruined  because  of  relapse  due  to  malaria.*  How- 
ever, even  this  circumstance  gave  the  Commission  an  opportunity 
to  find  the  loss  in  hemoglobin  during  relapse,  and  at  the  same  time 
to  discover  the  effect  of  insufficient  quinine  medication  in  malaria. 

The  cases  infected  with  both  malaria  and  hookworm  disease,  in 
whom  the  hemoglobin  had  been  reduced  below  normal,  were  treated 
thoroughly  and  at  once  with  quinine  for  the  purpose  of  arresting  the 
development  of  malaria  plasmodia,  and  in  order  to  put  a  stop  to  the 
losses  of  hemoglobin.  After  this,  it  was  possible  to  note  the  rate  of 
blood  regeneration  in  the  patients,  some  of  whom  were  harboring  few 
hookworms  and  some  of  whom  had  many.  By  noting  the  increase  in 
the  hemoglobin  and  the  increase  of  erythrocytes  at  stated  periods 
during  convalescence,  it  was  possible,  by  administering  chenopodium 
treatment  and  by  counting  the  number  of  worms  harbored,  to  ascer- 
tain the  rate  of  hematopoiesis  in  those  cases  that  were  convalescing 
from  malaria  who  harbored  few  hookworms,  and  among  those  cases 
that  were  convalescing  from  malaria  who  harbored  many  hookworms. 

In  order  to  determine  the  effect  of  harboring  a  large  number  of 
worms  (presumably  for  a  period  of  time  so  long  as  to  exhaust  the 
blood-forming  organs  to  a  degree  where  hematopoiesis  would  be  slower 
than  in  a  control  that  harbored  few  or  no  worms),  two  patients — as 
nearly  in  the  same  clinical  class,  so  far  as  age,  race,  hemoglobin 
content,  malaria,  etc.,  were  concerned  as  it  was  possible  to  obtain 
— were  selected  and  treated,  and  their  hookworms  were  recovered 
and  counted.  After  several  days  or  weeks,  the  rate  of  blood  regen- 
eration after  treatment  was  determined  and  the  results  were  com- 
pared. The  results  of  these  several  experiments  to  ascertain  the  rate 
of  blood  regeneration  in  malaria  and  hookworm  infection  may  be 
stated  as  given  below: 

a.  Blood  Regeneration  in  Uncomplicated  Hookworm  Infec- 
tion. In  instances  of  uncomplicated  hookworm  infection  among  the 
Chinese,  severe  cases  improved  very  slowly,  the  rate  of  increase  of 
hemoglobin  being  about  0.44  per  cent  per  diem.  It  appeared  to  be 
impossible  for  the  hemoglobin  to  return  to  normal  limits.  This  may 
have  been  due  to  the  bad  physical  condition  of  the  patients  treated, 
for  the  Chinese  usually  do  not  go  to  the  hospital  until  they  are  quite 
unable  to  continue  at  work. 

The  rate  of  increase  of  hemoglobin  in  the  Tamil  who  was  a  boy 
was  much  better,  being  1.0  per  cent  per  diem;  but  this  is  slower 

*  Result  of  insufficient  quinine  medication.  A  dishonest  employe  stole  some  of  the 
quinine  and  falsely  labeled  the  substituted  solution  that  was  used. 


FINDINGS   CONCERNING   ANEMIA  115 

than  the  rate  of  regeneration  after  malaria.  There  is  a  long  period, 
after  complete  removal  of  the  worms,  in  which  but  very  little  change 
in  the  hemoglobin  or  erythrocytes  is  noted.  This  period  consider- 
ably diminishes  the  per  diem  rate  of  increase. 

b.  Blood  Regeneration  in  Uncomplicated  Malaria  Infec- 
tion. It  was  difficult  to  discover  cases  of  uncomplicated  malaria. 
In  the  series  treated,  one  of  the  patients  continued  to  show  for  several 
days  evidences  of  malaria  by  the  presence  of  plasmodia.  This  symp- 
tom was  probably  due  to  insufficient  dosage  of  quinine.  His  rate 
of  blood  regeneration,  as  measured  by  the  increase  in  hemoglobin, 
was  1.2  per  cent  per  diem  during  a  period  of  32  days.  During  that 
period  while  he  had  no  plasmodia  in  his  blood,  the  rate  of  increase  in 
hemoglobin  was  1.4  per  cent  per  diem. 

Two  cases  that  had  been  previously  treated  for  hookworm  disease, 
and  presumably  were  free  from  worms,  had  relapses.  The  rate  of 
increase  in  hemoglobin  in  these  two  cases  was  1.6  per  cent  and  1.4 
per  cent;  the  increase  in  erythrocytes  was  1.4  per  cent  and  1.0  per 
cent  respectively  per  diem. 

In  the  cases  of  malaria  and  hookworm  disease  in  which  the  number 
of  worms  present  did  not  exceed  232  in  the  South  Indians  or  154  in 
the  Chinese,  the  hemoglobin  content  and  the  number  of  erythrocytes 
do  not  indicate  that  the  number  of  worms  present  interfered  meas- 
urably with  the  rate  of  increase.  A  patient  was  able  to  regenerate 
blood  after  malaria  as  rapidly  with  a  load  of  205  worms  as  if  he  had 
had  no  worms  at  all. 

When  the  malaria  was  associated  with  a  much  larger  number  of 
worms  it  was  difficult  for  a  patient  to  recover  promptly.  There 
were  only  two  cases  in  this  series  and  they  were  both  in  very  bad 
physical  condition  on  admission;  they  were  treated  early.  In  one  of 
these  cases  it  has  been  shown  that  the  burden  of  carrying  600  worms 
apparently  overtaxed  the  blood-forming  organs  to  an  appreciable 
extent,  for  the  rate  of  regeneration  after  removal  of  the  worms  was 
distinctly  slower  than  in  a  control  who  had  been  as  ill  from  malaria, 
but  who  had  harbored  only  a  few  worms.  But  it  must  be  noted 
that  this  particular  control,  who  showed  the  better  rate  of  improve- 
ment at  that  time,  returned  four  and  one-half  months  later  very 
badly  broken  down.  On  this  occasion  the v  rate  of  improvement 
was  not  so  good — in  fact  it  was  almost  as  bad  as  that  of  the  control 
carrying  the  600  hookworms.  These  data  serve  to  emphasize  the 
truth  that  the  blood-forming  organs  may  regenerate  well  enough 
under  a  strain,  provided  they  are  not  exhausted;  and  it  shows  that 
exhaustion  may  occur  with  malaria,  with  hookworm  disease,  or 
with  both. 

Greater  Severity  of  Anemia  in  Women.  Striking  and  appar- 
ently disproportionate  amounts  of  anemia  were  discovered  among 
the  women  on  certain  estates  where  there  was  severe  malaria  and 
among  the  night-soil  coolies  who  were  infected  with  hookworm  dis- 
ease and  malaria.  It  was  observed  that,  while  the  women  (as  a 


n6 


INTERNATIONAL   HEALTH   BOARD 


whole)  among  the  natives  in  some  malarious  kampongs  in  Java  had 
hemoglobins  usually  up  to  what  may  be  regarded  as  a  dessa  standard, 
pregnant  women — particularly  those  in  the  last  half  of  the  period  of 
pregnancy — showed  a  lower  value.  In  the  case  of  kampongs  where  the 
average  hemoglobin  of  the  pregnant  women  was  found  to  be  only 
64.1  per  cent,  this  fact  is  probably  not  to  be  regarded  as  altogether 
due  to  anemia,  but  to  hydremic  plethora,  for  women  have  a  mechan- 
ism for  the  production  of  hydremic  plethora;  this  mechanism  is 
normally  doubtless  controlled  by  their  endrocrinal  glands.  Some 
of  the  extreme  cases  of  anemia 
in  women  may  have  been  due 
to  a  perverted  functioning  of  the 
glands  as  a  result  of  severe 
malaria  infection.  The  greater 
instability  of  the  hemoglobin 
values  of  women  may  be  ob- 
served by  comparison  of  a  group 
in  those  kampongs  that  were 
free  from  malaria,  although 
heavily  infected  with  hookworm 
disease,  with  a  similar  group 
who  had  severe  malaria  and  but 
few  hookworms.  (See  Table  54, 
page  178.) 

It  will  be  observed  by  refer- 
ence to  this  table  that  the 
incidence  of  hemoglobins  59  per 


MEN    WOMEKCHILDRIH 


MEN  [WOMEN  ICHILOKN 


WOKEN  CHH.DKN 


1  CASES  WITH  HEMOGLOBIN  60  AND  OVER 
|  CASES  WITH  HEMOGLOBIN  59  AND  UNDER 
|  CASES  WITH  HEMO&D8N  60  AND  0»EflOlUllB01  V  WOW^ 
|  CASES  WITH  HEMOaoatt  59AKOUNDEB(  -    -      ••   ) 


Fig.  97. — Severity  of  anemia  in 
men,  women,  and  children.  Com- 
parative hemoglobin  rates  of  sexes 
in  malarious  and  non-malarious 
districts.  (Table  54) 


cent  and  lower  was  1\  times 
greater  among  women  than 
among  men,  among  the  treated 
cases  in  the  malarious  dessas, 
and  therefore  if  the  hemoglobin 
content  of  the  women  actually 
represented  anemia,  then  the 
amount  of  anemia  caused  by 
malaria  is  1\  times  greater  in 
women  than  in  men.  It  was  found  that  twenty-one  twenty-sixths, 
or  81  per  cent,  of  the  women  in  the  malarious  dessas  had  hemo- 
globins of  59  per  cent  and  lower,  while  only  four-fifteenths,  or 
26.6  per  cent,  of  the  women  who  lived  in  the  dessas  which  were 
non-malarious  but  which  were  heavily  infected  with  hookworm,  were 
in  the  same  hemoglobin  class.  It  is  therefore  safe  to  say  that 
malaria  causes  three  times  as  much  anemia  among  the  women  in 
these  kampongs  as  hookworm  disease  does  in  the  other  two  kam- 
pongs. The  fact  that  low  hemoglobin  values  were  found  in  preg- 
nant women — and  in  women  suffering  from  severe  anemia  due  chiefly 
to  malaria — should  be  kept  in  mind  in  estimating  the  average  hem- 
oglobins in  various  populations. 


FINDINGS   CONCERNING  ANEMIA  117 

Anemia  Among  Chinese  Coolies  in  Tin  Mines.  The  Com- 
mission examined  200  workers  in  a  tin  mine,  all  of  them  Chinese. 
One  hundred  specimens  of  feces  were  collected.  With  respect  to 
the  hemoglobin  content  of  these  men,  it  was  established  by  compari- 
son with  303  Chinese  prisoners  at  Penal  Institution  No.  2  that 
anemia  was  not  present  to  any  marked  extent  in  the  mine.  The 
lower  percentages  of  hemoglobin  found  in  the  jail  were  not  met  with 
among  the  workers  in  the  mine.  In  fact,  the  lowest  hemoglobin  in 
the  mine  series  was  45  per  cent,  while  the  lowest  in  the  jail  series  was 
35  per  cent.  This  difference  was  probably  due  to  the  fact  that  there 
was  a  weeding-out  process  at  the  mine,  whereas  all  sorts  and  condi- 
tions of  prisoners  were  admitted  and  retained  in  the  jail.  It  was 
found  that  the  higher  hemoglobins  among  the  mine  series  were 
slightly  inferior  to  those  found  in  the  jail,  the  highest  in  the  mine 
being  between  85  and  89  per  cent,  while  the  highest  in  the  jail  was 
between  90  and  94  per  cent.  This  difference  could  be  explained  as 
probably  due  to  the  better  conditions,  the  better  food,  etc.,  in  the 
jail,  and  also  to  the  fact  that  the  average  age  in  the  mine  series  was 
somewhat  higher  than  in  the  jail  series.  It  was  found  that  the  hemo- 
globin content  of  the  underground  workers  was  slightly  less  than 
that  of  the  surface  workers,  the  average  among  59  underground 
workers  being  83  per  cent,  and  the  average  among  141  surface  workers 
being  84.2  per  cent. 

One  hundred  stools  were  collected  and  examined.  Of  the  32 
underground  workers,  84  per  cent  were  found  positive  for  hook- 
worm disease,  and  79.4  per  cent  of  the  68  surface  workers.  Of 
100  of  the  stools  examined,  81  per  cent  were  found  to  contain  hook- 
worm ova,  which  is  almost  exactly  the  same  percentage  as  that  ob- 
tained by  examination  of  the  feces  of  prisoners  in  the  jails,  i.  e.,  80.3 
per  cent. 

No  correlation  was  observed  between  the  degree  of  hookworm  in- 
fection and  the  amount  of  anemia,  for  although  the  underground 
workers  were  shown  to  have  the  lower  hemoglobins  (a  fact  quite  in 
accord  with  their  greater  infection  with  hookworm)  the  cases  found 
infected  with  hookworm  showed  no  anemia  when  compared  with 
the  cases  not  infected.  That  is,  the  average  hemoglobin  of  81  cases 
infected  with  hookworm  was  found  to  be  85.1  per  cent,  while  the 
average  hemoglobin  of  19  cases  found  to  be  not  infected  with  hook- 
worm was  80.8  per  cent. 

As  for  malaria,  it  was  found  to  be  unimportant.  Enlarged  spleens 
were  found  in  25  of  the  200  cases,  i.  e.  12.5  per  cent.  The  cases  with 
enlarged  spleens  and  average  hemoglobin  were  78.6  per  cent.  The 
other  175  cases  had  an  average  hemoglobin  of  84.5  per  cent.  Blood 
examinations  were  made  of  162  cases,  and  3  of  these,  or  1.9  per 
cent,  were  found  positive  for  malaria  plasmodia,  their  average  hem- 
oglobin being  68.3  per  cent. 


TABULAR  SUMMARY 


120 


INTERNATIONAL   HEALTH    BOARD 


C/3 

W 

H 


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INDEX 

PAGE 

ACACIA 27 

AGAR,  SOLUTION  OF  NUTRIENT: 

In  centrifuge  method 25 

ALBUMINURIA 39-40 

ANCYLOSTOMA  CEYLANICUM 55, 56, 60 

ANCYLOSTOMA  DUODENALE: 

Importance  of  distribution  and  relative  numbers 55 

Comparative  malignancy 106, 109, 110 

Also 55, 56, 57,  58, 59, 60, 63, 99, 102 

ANCYLOSTOME  FORMULA 55 

ANCYLOSTOME  INDEX: 

Clue  to  ethnic  origin 64 

ANCYLOSTOMES: 

Experiments  on  relative  resistance  of  sexes  to  vermicides 47-49 

Mouth  parts 52 

Conditions  limiting  proportions 55 

Percentage  among  adult  Malays 56 

Percentage  among  Chinese  at  District  Hospital,  Kuala  Lumpur.  .     56 

Percentage  among  Tamils ._ 57 

Percentage  among  night-soil  coolies  at  Kuala  Lumpur 57 

Percentage  among  road  coolies 58 

Percentage  among  Sikhs 58-59 

Among  Japanese 59 

Percentage  in  Java 60 

Also 20, 33, 34, 35, 41, 56 

See  also  Names  of  species 

ANEMIA: 

Correlated  with  worms  and  splenic  enlargement 80, 92 

Result  of  malaria  and  hookworm  disease 90-91,  92, 93 

Other  causal  factors 93 

Amount  due  to  malaria ' 94 

Quantitative  value  of  hookworms  as  cause 95 

Relation  to  hookworm  disease  in  Fiji 101 

Investigations  on  varying  degrees  caused  by  hookworms,  102-104,  106 
Experiments  on  comparative  malignancy  of  hookworms,    106,  109, 110 

Among  Chinese  and  Tamil  coolies 112 

Severity  in  women 115,116 

Among  Chinese  coolies  in  tin  mines 117 

Also 12 

See  also  Hemoglobin 

ANOPHELES  KAWARI 68 

179 


ISO  INDEX 

PAGE 

ANOPHELES  KOCHI 68 

ANOPHELES  LUDLOWI 68, 69 

ANOPHELES  MACULATUS 69 

ANOPHELES  Rossi 68 

ANOPHELES  TESSELLATUS 68 

ANOPHELES  UMBROSUS 68 

ANOPHELINES: 

Species  occurring  at  Port  Swettenham 68 

ASCARIS 33 

ASCITES 110 

BALI,  EAST  INDIES 63, 64 

BARBADOS 8,  81 

BARBER,  DR.  MARSHALL  A.: 
Member  Uncinariasis  Commission  to  the  Orient 15 

B  ATA  VIA: 

Percentage  of  ancylostomes  at  jail 60 

Incidence  of  hookworm  infection  and  malaria  in  jail 77-78 

Correlation  between  presence  of  malaria  and  number  of  worms 

among  prisoners 78 

Average  hemoglobin  of  boys  in  kampong 88 

Causes  of  anemia  among  prisoners 93 

Also 102, 104 

BATAVIA  GEFANGENIS 104 

BATAVIA  JAIL,  see  BATAVIA 

BATAVIA  STADSVERBAND 101 

BEADS,  GLASS: 

For  identification  of  specimens  in  fecal  examinations 28 

BENGALESE 21 

BERIBERICS 88-89,101,104 

BETA-NAPTHHOL 34 

BLOOD,  EXAMINATION  OF: 

At  District  Hospital,  Kuala  Lumpur 65-66 

Parasitic  rates  at  Port  Swettenham 67 

Resume  of  findings  by  the  Commission  in  the  Federated  Malay- 
States  67-68 

In  a  case  of  malaria  mistaken  for  hookworm  disease 110 

See  also  Erythrocytes;  Hemoglobin 

BLOOD  REGENERATION: 

Investigations  on  effect  of  hookworm  infection 111-114 

In  uncomplicated  hookworm  infection 114-115 

In  uncomplicated  malaria  infection 115 


INDEX  l8l 

PAGE 

BOYS: 

Percentage  of  hookworms  at  Kampong  BharuandUluGombak,  55-56 
Investigations  on  standard  normal  content  of  hemoglobin,  87-88,  89-90 

Calculated  normal  hemoglobin  at  Gebongelir 95 

Number  of  worms  required  to  cause  loss  of  1  per  cent  of  hemo- 
globin       93 

See  also  Schools 

CACHEXIA 65 

CALOMEL 42 

CASTOR  OIL 27,  34, 39-40, 42 

CELEBES,  EAST  INDIES 63 

CENTRIFUGE  METHOD: 

Details  of  procedure  and  comparison  of  methods 25-27 

See  also  Smear  method 

CEYLON _ 12 

CHENOPODIUM,  see  OIL  OF  CHENOPODIUM 

CHILDREN: 

Thymol  in  treatment 35 

Examined  for  hookworm  infection 47, 69 

Percentage  of  hookworm  infection  at  Singapore 52-53 

Spleen  rate 67 

Average  hemoglobin  content  in  Java 84, 87 

Ratio  of  loss  of  hemoglobin  to  number  of  worms 100 

Hemoglobin  rates  in  Fiji 100 

Also 102 

See  also  Boys;  Girls;  Schools 

CHINESE  COOLIES: 

Personal  characteristics 3-4 

Compared  with  Tamils 4,  112-113 

Value  as  laborers 4 

Examination  and  treatment 16,  21 

Mortality  from  hookworm  disease  and  malaria  in  District  Hospi- 
tal, Kuala  Lumpur 51-52 

Worm-species  formula 56 

Percentage  of  hookworms  among  sinkehs  in  Singapore 56,  59,  84 

Necator  americanus  among  Straits-born  Chinese 57 

Ratio  of  loss  of  hemoglobin  to  number  of  worms 99 

Investigations  on  rate  of  blood  regeneration 111-114 

Also 34 

CHLOROFORM . .    34 

COLONIAL  JAIL,  SUVA,  see  PRISONERS 

CONVENT  SCHOOL,  KUALA  LUMPUR,  see  SCHOOLS 

COOLIES,  see   CHINESE    COOLIES;   INDENTURED   COOLIES;   INDIAN 
COOLIES;  NIGHT-SOIL  COOLIES;  ROAD  COOLIES;  TAMIL  COOLIES 


I 82  INDEX 

PAGE 

DARE'S  INSTRUMENT 84 

DARLING,  DR.  SAMUEL  T. 

Appointed  Chairman  of  Uncinariasis  Commission  to  the  Orient.  .  15 

DEMENTIA  PRAECOX 41 

DETENTION  CAMPS,  see  PORT  SWETTENHAM;  SINGAPORE 

DIARRHEA 110 

DISTRICT  HOSPITAL,  KUALA  LUMPUR,  FEDERATED  MALAY  STATES: 
Permanent   headquarters   of   Uncinariasis    Commission    to    the 

Orient 16 

Examinations  for  plasmodia  and  hookworm  ova 21 

Experiments  in  administration  of  vermicides 33 

Comparative  fatality  of  malaria  and  hookworm  disease 51 

Incidence  of  fatal  disease  shown  by  post-mortems 51 

Percentage  of  hookworms  among  Chinese 56 

Fatalities  from  malaria 65 

Also 5, 16, 42, 104, 11 1 

See  also  Kampong  Bharu 

DYSENTERY 21,51 


EAST  JAVA 60,63,64 

EDEMA 110,111 

EGYPT 12 

ENDIL,  JAVA 64, 74 

ERYTHROCYTES: 

Loss  after  treatment  by  chenopodium 38-39 

Also Ill,  114, 115 

See  also  Blood  Regeneration;  Hemoglobin 
ESTATES: 

Re-examination  of  coolies  for  hookworm  infection 19-20 

Malaria  survey 69-70,73-74 

EUCALYPTUS  .  -. 34 

EURASIANS 21 

EUROPEANS 21, 59 


FECES,  EXAMINATION  OF: 

Identification  of  specimens 27-28 

Washing  of  stools 28,  31 

Collection  of  stools 32-33 

At  Port  Swettenham 47 

At  District  Hospital,  Kuala  Lumpur 66 

See  also  Centrifuge  Method;  Smear  Method 


INDEX  183 

PAGE 

FEDERATED  MALAY  STATES: 

Organized  public  health  work 5,7 

Examination  of  children,  miners,  hospital  patients,  prisoners  and 

coolies ...  - .• :  .     20 

Relative  seriousness  of  malaria 90 

Analysis  of  cases  treated  for  hookworm  disease 95-96 

Also 12, 81 

See  also  Names  of  places 
FIJI  ISLANDS: 

Climate 8 

Characteristics  of  natives  .  . .  - 8 

Indian  coolies 8,11 

Prevalence  of  hookworm  infection 53, 101 

Malaria  not  endemic 82 

Examinations  for  anemia 100-101 

See  also  Names  of  places 

FIJI  MEDICAL  DEPARTMENT 53 

FILARIA 82 

GEBONGELIR,  JAVA 60,74,93,95 

GIRLS: 

Calculated  normal  hemoglobin  at  Gebongelir 95 

Also 20, 95 

See  also  Schools 
GLASS  BEADS: 

For  identification  of  specimens  in  fecal  examinations 28 

GLYCERINE 22,25 

HACKER,  DR.  H.  P. 

Member  Uncinariasis  Commission  to  the  Orient 15 

HASTING'S  STAIN 82 

HEMATOPOIESIS 114 

HEMOGLOBIN: 

After-effects  of  treatment  by  vermicidal  drugs 38-39 

Percentage  at  Singapore 52-53 

Gains  and  losses  affected  by  malaria  and  hookworm  disease.  .  70,  73-74 

Average  for  malarial  and  non-malarial  groups  in  Java  jail 78 

Influences  of  sex  and  age  on  values 83-84 

Averages  given  by  Dare's  instrument 84 

Measures  to  determine  normal  average  content 84 

Effect  of  pregnancy 84,  89, 101, 116 

Control  determinations  of  members  of  the  Commission 87 

Investigations  on  standard  normal  content  in  a  mixed  population,  87-88 
Rates  among  beriberics  and  prisoner  clerks  in  Batavia,  88-89, 101-102 
Numbers  of  worms  required  to  cause  loss  of  1  per  cent  .  .89, 91, 92-93 

Losses  due  to  hookworm  disease 92, 99 

Influence  of  diet  and  hard  labor 93-94, 104 


184  INDEX 

PAGE 

HEMOGLOBIN — continued 

Estimate  of  loss  due  to  malaria 94 

Comparison  in  sex  and  age  groups 95 

Losses  compared  by  various  worm  groups 95-96,99-100 

Representative  male  standard 102 

Average  rates  among  indentured  coolies  and  prisoners 102-104 

Fijian  treatment  squad 106 

In  a  malaria-free  group 106 

In  a  case  of  malaria  mistaken  for  hookworm  disease 111-112 

Difficulty  of  raising  value 113 

See  also  Blood  Regeneration 
HOOKWORM  DISEASE: 

Prevalence  in  the  Orient 12 

In  relation  to  malaria 15, 70, 74,  77-79 

Treatment  of  coolies  at  detention  camps 16 

Results  of  re-examination  on  estates 19-20 

Infection  among  children 47 

Post-mortems  at  District  Hospital,  Kuala  Lumpur 51-52 

Comparative  severity  between  Chinese  and  Tamil  coolies 51-52 

Percentage  of  infection  at  Singapore 52-53 

Prevalence  in  the  Fiji  Islands 53,55 

Sources  of  infection  among  Europeans  and  Chinese  in  Federated 

Malay  States 59 

Examinations  at  District  Hospital,  Kuala  Lumpur 66 

Among  children  with  low  hemoglobin  average 69 

Correlation  between  presence  of  malaria  and  number  of  worms ....     78 

Splenic  enlargement  and  high  worm  counts 80-81 

Lowest  incidence  of  infection 84, 87 

Relative  seriousness  in  Federated  Malay  States  and  Java 90 

Cause  of  lowered  hemoglobin  values 92, 93 

Effect  on  hemoglobin  among  prisoners  in  Java 94 

Factor  in  producing  malaria  at  Gebongelir 95 

Analysis  of  cases  treated  in  Federated  Malay  States  .  .  .95-96,99-100 

Relation  to  anemia  in  Fiji 101-105 

Effect  on  blood  regeneration 111-114 

Also 21, 70, 73, 74, 77, 82, 83, 109-110 

See  also  Vermicidal  Treatment  for  Hookworm  Disease 
HOOKWORM  OVA,  DETECTION  OF,  see  FECES,  EXAMINATION  OF 
HOOKWORMS: 

Percentage  of  removals 50-5 1 

Percentage  among  boys  at  Ulu  Gombak 55 

Differentiation  and  distribution  of  species 55-57 

Percentage  among  adult  Malays 56 

Number  required  to  produce  a  loss  of  1  per  cent  hemoglobin 

89,  91,  92-93 
Experiments  on  comparative  malignancy 106, 109-110 

See  also  Names  of  species 


INDEX  185 

PAGE 

INDENTURED  COOLIES: 

Standards  of  hemoglobin 102-103 

INDIAN  COOLIES 8, 1 1, 101 

INTERNATIONAL  HEALTH  BOARD: 

In  co-operation  with  the  Fiji  Medical  Department 53 

Also 12, 15 

JAAGPAD,  JAVA 74 

JAILS,  see  BATAVIA;  PRISONERS;  SUVA,  FIJI  ISLANDS;  TAIPING  JAIL, 

FEDERATED  MALAY  STATES 
JAPANESE: 

Percentage  of  ancylostomes  among  prostitutes 59 

Also 21 

JAVA: 

Native  population 7 

Hookworm  infection  and  malaria 21 

Correspondence   between   malaria   and   hookworm   infection   in 

kampongs 74, 77 

Investigations  on  standard  normal  content  of  hemoglobin 87-88 

Relative  seriousness  of  hookworm  disease 90 

Findings  on  hemoglobin  values 92 

Also 2, 81, 99, 104 

See  also  Names  of  places 
JAVA  JAIL,  see  BATAVIA 
JOHORE,  FEDERATED  MALAY  STATES 5 

KAJANG,  FEDERATED  MALAY  STATES 1 10 

KALIMARO,  JAVA 60, 77, 87, 88, 89, 90, 92, 95 

KAMPONG  BHARU,  FEDERATED  MALAY  STATES 20,  55 

KEBASEKAN,  JAVA 60, 77,  88, 89, 90, 92, 95 

KIDNEYS,  see  URINE 

KRAKAL,  JAVA 77 

K.RAKAL-K.ARANGSARI,  JAVA 60 

KRAMAT,  JAVA 89, 90, 92 

KUALA  LUMPUR,  see  District  Hospital,  Kuala  Lumpur,  Federated 
Malay  States 

LOMBAK,  EAST  INDIES 63 

MADRAS  PRESIDENCY 3 

MADURA,  EAST  INDIES 63 

MAGNESIUM  SULPHATE 27,  32,42 

MALACCA 57 

MALABARIS  .  .  57,111 


I 86  INDEX 

PAGE 

MALARIA: 

Not  co-extensive  with  hookworm  disease 8 

Surveys  in  vicinity  of  Kuala  Lumpur 16 

Fatalities  at  District  Hospital,  Kuala  Lumpur 51 

Post-mortems  at  District  Hospital,  Kuala  Lumpur 65 

Survey  at  Port  Swettenham 68-69 

Surveys  on  estates 69-70, 73-74 

Relation  to  hookworm  disease  on  kampongs  in  Java 74, 77-78 

Among  prisoners  in  Java 80 

Results  of  control  investigations  at  Viti  Levu 81-82 

Lowest  incidence  of  infection 84-87 

Relative  seriousness  in  Federated  Malay  States  and  Java.  .'.....      90 

Effect  on  hemoglobin 99 

Mistaken  for  hookworm  disease 1 10 

Effect  of  hookworm  infection  on  blood  regeneration 111-114 

Also 12, 15 

See  also  Blood,  Examination  of;  Blood  Regeneration 

MALAY  PENINSULA: 

Topography  and  climate 1 

Population 2-3 

Schools 4 

Principal  industries 4-5 

Under  British  protection 5 

See  also  Federated  Malay  States;  Singapore 

MALAYS: 

Percentage  of  hookworms 55-56 

Also 21, 34 

MAL-NUTRITION,  see  SUB-NUTRITION 

MEN: 

Average  normal  hemoglobin 88-90 

Number  of  worms  required  to  cause  loss  of  1  per  cent  of  hemo- 
globin       93 

Calculated  normal  hemoglobin  at  Gebongelir 95 

Ratio  of  loss  of  hemoglobin  to  number  of  worms 99, 100 

Hemoglobin  rates  in  Fiji 100 

MICROSCOPIC  SLIDES 22, 25 

MID-JAVA • 60,63,64 

MOHAMMEDAN  POLICE,  see  SIKHS 

MOHAMMEDANS 2 

MURUGAN,  A  TAMIL  DHOBY 110-111 

NaCl,  SATURATED  SOLUTION  OF 22, 25 

NASAQO,  FIJI  ISLANDS 82 

NAUSORI,  FIJI  ISLANDS 81, 82, 101, 102 

NAUSORI  INDIANS  .  .  .   106 


INDEX  187 

PAGE 

NEGATOR  AMERICANUS: 

Experiments  on  relative  resistance  of  sexes  to  vermicides 47-49 

Mouth  parts 52 

Natural  parasite  of  Fijians 55 

Conditions  limiting  proportions 55 

Among  Straits-born  Chinese 57 

Comparative  malignancy 106, 109, 110 

Also 20, 33, 34, 35, 41, 55, 56, 57, 58, 59, 60, 63, 99, 102 

NEGRI  SEMBILAN,  FEDERATED  MALAY  STATES 5 

NIGHT-SOIL  COOLIES: 

Examinations  for  comparative  study 20 

Percentage  of  ancylostomes 58 

NON-FEDERATED  MALAY  STATES 5 

NORTH  INDIANS,  see  SIKHS 

OIL  OF  CHENOPODIUM: 

Method  of  administering 27 

Comparison  with  thymol 33-34, 35 

Form  and  dosage 34, 36 

Price  per  mil  and  relative  cost  of  treatment 36-37 

Toxic  effects  upon  the  kidneys 39-41 

Symptoms  of  dementia  praecox 41 

Causes  vomiting 41^12 

Percentage  of  worms  removed  by  first  and  second  treatments.  ...     50 
Also 16, 78, 110, 114 

OVA,  DETECTION  OF,  see  FECES,  EXAMINATION  OF 

PAHANG,  FEDERATED  MALAY  STATES 5 

PANGHOR  TREATY 5 

PENANG,  STRAITS  SETTLEMENTS 12 

PERAK,  FEDERATED  MALAY  STATES 5 

PHILIPPINE  ISLANDS 12 

PLASM  ODIA: 

Positive  and  negative  evidence  of  malaria 77-78 

Analysis  of  cases  with  regard  to  relation  of  worms 78-79 

Among  prisoners 80 

Also 21,65,111-112 

See  also  Blood,  Examination  of;  Malaria 

POLYNESIANS 82 

PORT  SWETTENHAM,  FEDERATED  MALAY  STATES: 

Quarantine  camp  and  examination  of  Tamil  coolies 16, 19 

Examinations  for  hookworm  infection 25-26,47 

Results  of  treatment  for  hookworm  infection 57 

Spleen  examinations  among  coolies 66 


1 88  INDEX 

PAGE 

PORT  SWETTENHAM — continued 

Results  of  blood  examinations 67 

Malaria  survey 68-69 

Results  of  examinations  for  hemoglobin  rates 70, 73-74 

Also 8, 52, 84, 95 

POST-MORTEM  EXAMINATIONS 51, 65 

PREANGER,  JAVA 60 

PREGNANCY,  see  WOMEN 

PRISONERS: 

Comparison  with  mine  workers 21 

Percentage  of  ancylostomes  at  jail  in  Sumatra 63 

Malaria  survey  at  Colonial  jail,  Suva 81 

Deficient  in  hemoglobin 102 

See  also  Batavia;  Taiping  Jail 

PROSTITUTES 59 

PURGES: 

Comparative  values 42 

See  also  Names  of  drugs 

QUARANTINE  CAMPS,  see  PORT  SWETTENHAM;  SINGAPORE 

QUININE 110,114,115 


REWA  RIVER,  FIJI  ISLANDS 81,  82 

ROAD  COOLIES: 

Percentage  of  ancylostomes 58 


ST.  JOHN'S  ISLAND,  see  SINGAPORE 

SAWAH  BESAR,  JAVA 92 

SCHOOLS: 

Treatment  at  Kampong  Bharu 20 

Treatment  at  Convent  school  at  Kuala  Lumpur 20 

Examination  of  students  at  Victoria  school 21 

Hemoglobin  rates  at  Victoria  school 101 

Also i 82 

See  also  Boys;  Children;  Girls 

SELANGOR,  FEDERATED  MALAY  STATES 5 

SENNA 42 

SIKHS: 

Percentage  of  ancylostomes  in  the  Federated  Malay  States 58-59 

Also ' 2,21 

SlNGALESE 21 


INDEX  189 

PAGE 

SINGAPORE,  STRAITS  SETTLEMENTS: 

Percentage  of  hookworms  among  sinkehs  at  St.  John's  Island.  ...     56 

Results  of  examinations  at  St.  John's  Island 52-53, 84 

Also 12, 16, 95 

SINKEHS 56,  59,  84 

SLIDES,  MICROSCOPIC 22, 25 

SMEAR  METHOD: 

Details  of  procedure 22, 25 

Comparison  of  methods 25-27 

See  also  Centrifuge  Method;  VermicidalJTreatment  for  Hook- 
worm Disease 

SODIUM  SULPHATE 27 

SOUTH  INDIANS,  see  Malabaris;  Telegus 

SPLEEN: 

Examination  and  classification 66-67 

Rate  among  children 67 

Rates  in  Java  kampongs 74 

As  evidence  of  malaria 77-78 

Enlargement  among  prisoners  in  Java 80-81 

Results  of  control  investigations  at  Fiji 82 

Also 79 

See  also  Blood,  Examination  of;  Plasmodia 

SPOROZOITES 68 

STOOLS,  see  FECES,  EXAMINATION  OF 

STRAITS-BORN  CHINESE 57 

STRAITS  SETTLEMENTS 2 

See  also  Singapore 

SUB-NUTRITION: 

Cause  of  anemia 93 

Native  population 7 

SUMATRA: 

Investigation  of  methods  of  treating  hookworm  disease 21 

Percentage  of  ancylostomes 63 

Also 64,  81 

SUVA,  FIJI  ISLANDS: 

Low  hemoglobin  among  Indians  in  jail 102 

Also 81, 82, 104, 106 


TAIPING  JAIL,  FEDERATED  MALAY  STATES: 

Clinical  examinations 21 

Routine  technique  of  treatment 32-33 

Experiments  with  vermicides 34 

Also.. 


INDEX 

PAGE 

TAMIL  COOLIES: 

Origin  and  characteristics 3 

Compared  with  Chinese 4, 112-113 

Examination  and  treatment 16,  21 

Details  of  examination  at  Port  Swettenham 19 

Re-examination  on  estates 19-20 

Mortality  from  hookworm  disease  and  malaria  in  District  Hos- 
pital, Kuala  Lumpur 51-52 

Percentage  of  ancylostomes 57 

Infection  from  Chinese  sources 57-58 

Hemoglobin  determinations 84 

Ratio  of  loss  of  hemoglobin  to  number  of  worms 99 

Investigations  on  rate  of  blood  regeneration 111-114 

Religious  and  caste  restrictions 112 

Also 34 

TELEGUS 57 

TEST  TUBE,  see  CENTRIFUGE  METHOD 

THYMOL: 

Comparison  with  oil  of  chenopodium 33-34,  35, 42 

Form  and  dosage 27,  34 

Price  per  grain  and  relative  cost  of  treatment .  .  . 36-37 

Toxic  symptoms 41 

Also 16 

TIMOR,  EAST  INDIES 63 

TIN  MINES: 

Results  of  examinations  for  hookworm  disease  and  comparison 

with  prisoners  at  Taiping  jail 20-21 

Also 5 

TREATMENT  FOR  HOOKWORM  DISEASE,  see  VERMICIDAL  TREATMENT 
FOR  HOOKWORM  DISEASE 

TRICHURIS 33 

TUBERCULOSIS  .  . .  .- 51 

ULU  GOMBAK,  FEDERATED  MALAY  STATES: 

Treatment  of  boys  for  hookworm  disease 55-56 

UNCINARIASIS  COMMISSION  TO  THE  ORIENT: 

Field  of  operations 2 

Preliminary  tour  by  the  General  Director  of  the  International 

Health  Board 12 

Attitude  of  British  Government 12 

Appointed  by  the  International  Health  Board 12, 15 

Personnel  and  purpose 15 

Headquarters  at  Kuala  Lumpur 16 

Methods  of  inquiry 16 

Results  of  investigations 21 


INDEX 

—  s~ 
PAGE 

UNCINARIASIS  COMMISSION  TO  THE  ORIENT — continued, 

Control  determinations  of  hemoglobin  of  members 87 

Decision  regarding  malaria 90 

URINE: 
Tests  on  presence  of  chenopodium 39, 41 

VANIMORA,  FIJI  ISLANDS 82 

VERMICIDAL  TREATMENT  FOR  HOOKWORM  DISEASE: 

Details  of  procedure 27 

Routine  technique 32-33 

Series  conducted  at  Kuala  Lumpur 33-34 

Experiments  at  Taiping  jail 34-35 

Series  to  determine  action  and  results  of  different  doses  of  chen- 
opodium       36 

Relative  costs 36-37 

After-effects 37-39 

Diet 42 

Comparative  effects  of  higher  and  lower  doses 49 

Comparative  results  of  first  and  second  treatments 50-51 

See  also  Names  of  Drugs 

VICTORIA  SCHOOL,  see  SCHOOLS 

VITI  LEVU,  FIJI  ISLANDS: 

Field  for  intensive  study  of  hookworm  disease 8 

Control  investigations  on  hookworm  disease 21 

Percentage  of  hookworm  infection 53 

Control  investigations  on  malaria 81-82 

Hemoglobin  rates 100 

VOMITING: 

Caused  by  chenopodium  and  thymol 37-38, 41-42 

WEST  JAVA 60, 63 

WOMEN: 

Effect  of  pregnancy  on  hemoglobin 84, 89, 101, 116 

Average  hemoglobin 89-90 

Calculated  normal  hemoglobin  at  Gebongelir 95 

Rate  of  loss  of  hemoglobin  to  number  of  worms 100 

Hemoglobin  rates  in  Fiji 

Severity  of  anemia  during  pregnancy 115-116 

Also 102 

WORM-SPECIES  FORMULA: 

Of  the  Chinese ^6 

For  Straits-born  Chinese  and  South  Indians 57-58 

Among  Sumatrans "* 

WORMS,  see  HOOKWORMS 


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